A True Love Story of How Larry & Sandy Met

Finding your soulmate is like discovering the missing link in your heart. When that special someone enters your life, has similar values, ideals and beliefs and lives them as well, you discover that the two pieces of the relationship puzzle fit perfectly together. There are many souls you connect with in this life. With some you feel an immediate bond that you know will always be there.

I first met my soulmate when we were very young. This is a story of four people who loved each other, had fun together, then were separated by time and distance. Twenty-six years later two of them were reunited by very unexpected circumstances.

My best friend, Ted Charveze, and I were both very active in the Topeka Jaycees. We spent a lot of time together. He was best man at my wedding. His wife, Sandy, my wife and I were all close friends. After six years of doing things together as couples and enjoying each others company, my family moved to Tulsa so that I could take a position of management with a major real estate firm.

About two years later, Ted and Sandy moved to Scottsdale, Arizona to be close to his mentor and to take advantage of a better opportunity to promote his work as a jewelry artisan. Even though we had all been close friends, we lost contact.

About 8 years ago, while cleaning out some drawers, my former mother-in-law found a "one year old" obituary notice saying that Ted had died. In spite of a divorce several years earlier from her daughter, we had remained friends. She sent me the obituary notice along with a note to inform me of his passing. I did not know.

The notice revealed that Sandy was living in Scottsdale. I called to express my sympathy. She told me that not only had Ted died, her 25 year old daughter had died suddenly less than a year and a half before. In addition, her mother-in-law, father and a sister had also died. She had been grieving for a long time.

Three years later, on her birthday, I received a message on my voice mail. It said, "Hi Larry. I was just thinking about you. Thought you might like to talk sometime. Call me if you want to!" CLICK!! There was no name, no number and a voice I had only heard once in about 26 years. After listening to the message over and over, I decided that it might be Sandy, so I called. It was.

continue story below

Since the last time I had talked with her, I had been in a relationship that was suddenly over. A year had passed since that relationship and I had spent most of my time focusing my energy on working on me. The first six months I saw a therapist who helped me work through the pain of a changing relationship. In the first therapy session, I discovered that I had no guidelines for a relationship. I had always done the best I could, but it never seemed good enough. I became a full-time student of relationships. I read every book my therapist recommended. I began writing a daily journal. It was a painful process. As I began to feel better about myself, I began to write my own relationship guidelines. I gave them to my therapist for review and he encouraged me to write more and publish them.

When Sandy called, my first relationship book, "How to Really Love the One
On December 20th I sent the book. The day after Christmas I called her. We talked for about an hour about the book and relationships. Four days later I accepted her invitation to go to Scottsdale for a brief holiday.

We were both very nervous about meeting after so many years. We TALKED about our fears and the conversation defused our anxiety. When we met we spent a lot of time talking about the "good old days" when she and her husband and my wife and I had spent many happy times together. We acknowledged that even back then, we had some kind of special attraction for each other, but neither chose to pursue it because we were both married to someone else. We visited some of her favorite places to eat and had a wonderful time just talking and getting to know each other again.

We both talked about how we enjoyed being alone. We were very clear that neither she nor I were interested in a relationship together or with anyone else at the time. We were learning to be ourselves, enjoyed being alone without experiencing loneliness.

We both truly enjoyed each others conversation and as time passed, we got to know each other better on the phone. Several months later I presented a "Relationship Enrichment LoveShop" in the Phoenix area and took time to see her again. Sandy's daughter lived in Topeka, which was a four and a half hour drive from Tulsa. Whenever she would visit her daughter, I would drive to Topeka to see her. She also made several trips to Tulsa.

The hours we talked on the phone, for months never suspecting that we would ever be together, was a time of building the foundation of trust that healthy love relationships need to make them work. Finding the right person is more about being the right person. We were preparing for love. The walls of resistance were coming down. We talked openly and honestly about our feelings about life, relationships and each other. We discovered that we could express our own individuality and still choose to be together. The fears of our wounded hearts somehow melted away. When two whole people come together, they enhance each other's lives more than one can alone. As time passed we both became aware that we were growing in love and toward each other.

A soulmate is not someone you need to be happy. A soulmate is someone you share your happiness with.

After an eighteen month long-distance relationship (and hundreds of dollars in phone bills) we began to talk about being together, not really sure we wanted to give up our independence. Several months later I moved to Scottsdale to be with her. She admitted to me later that when she saw me pull the big U-Haul truck into her drive, she said to herself, "Oh, my! What have I done!"

I married my best friend's wife on June 8, 1996. God smiled on both of us that day. We are both confident that Ted smiled too, and that we have his blessing.

Since then I have written two more books on relationships and am on staff with Dr. John Gray, Ph.D., author of "Men Are From Mars, Women Are From Venus." Sandy made the connection to Dr. Gray by attending his seminar and giving him one of my books. Dr. Gray has endorsed all of my books.

Sandy and I are a team. Whenever she can, Sandy travels with me to present my Relationship Enrichment LoveShops across the country. We are both committed to have our relationship be the kind of example we can both be proud to share with others. We continually search for new and creative ways to keep the romance, passion and the fire of love burning. We, like other couples have our ups and downs, and we have learned that relationships are something that must be worked on all the time, not only when they are broken and need to be fixed.

SoulMates? You bet! A great relationship? Definitely! Trust is the foundation of a healthy love relationship. There can be no trust without conversation; no genuine intimacy without trust!

Sandy is my very best friend. She supports my dreams, accepts me for who I am and loves me unconditionally. We were truly meant to be together. With so much time passing, it is truly a miracle that we were brought together at all. This soulmate journey took over 30 years!

continue story below

next: A Prayer of Thanksgiving

Articles I wrote on co-dependence recovery topics and how they applied to my life. Includes admitting powerlessness, what recovery is, and more.

View top ten topics by reader statistics

next: Top Co-Dependence Recovery Topics

Iron is an important component of good health. Detailed information on iron intake, iron deficiency and iron supplements.

Table of Contents

• Iron: What is it?
• What foods provide iron?
• What affects iron absorption?
• What is the recommended intake for iron?
• When can iron deficiency occur?
• Who may need extra iron to prevent a deficiency?
• Does pregnancy increase the need for iron?
• Some facts about iron supplements
• Who should be cautious about taking iron supplements?
• What are some current issues and controversies about iron?
• What is the risk of iron toxicity?
• Selecting a healthful diet
• References

Iron: What is it?

Iron, one of the most abundant metals on Earth, is essential to most life forms and to normal human physiology. Iron is an integral part of many proteins and enzymes that maintain good health. In humans, iron is an essential component of proteins involved in oxygen transport [1,2]. It is also essential for the regulation of cell growth and differentiation [3,4]. A deficiency of iron limits oxygen delivery to cells, resulting in fatigue, poor work performance, and decreased immunity [1,5-6]. On the other hand, excess amounts of iron can result in toxicity and even death [7].

Almost two-thirds of iron in the body is found in hemoglobin, the protein in red blood cells that carries oxygen to tissues. Smaller amounts of iron are found in myoglobin, a protein that helps supply oxygen to muscle, and in enzymes that assist biochemical reactions. Iron is also found in proteins that store iron for future needs and that transport iron in blood. Iron stores are regulated by intestinal iron absorption [1,8].

What foods provide iron?

There are two forms of dietary iron: heme and nonheme. Heme iron is derived from hemoglobin, the protein in red blood cells that delivers oxygen to cells. Heme iron is found in animal foods that originally contained hemoglobin, such as red meats, fish, and poultry. Iron in plant foods such as lentils and beans is arranged in a chemical structure called nonheme iron [9]. This is the form of iron added to iron-enriched and iron-fortified foods. Heme iron is absorbed better than nonheme iron, but most dietary iron is nonheme iron [8]. A variety of heme and nonheme sources of iron are listed in Tables 1 and 2.

Table 1: Selected Food Sources of Heme Iron [10]

References

Table 2: Selected Food Sources of Nonheme Iron [10]

*DV = Daily Value. DVs are reference numbers developed by the Food and Drug Administration (FDA) to help consumers determine if a food contains a lot or a little of a specific nutrient. The FDA requires all food labels to include the percent DV (%DV) for iron. The percent DV tells you what percent of the DV is provided in one serving. The DV for iron is 18 milligrams (mg). A food providing 5% of the DV or less is a low source while a food that provides 10-19% of the DV is a good source. A food that provides 20% or more of the DV is high in that nutrient. It is important to remember that foods that provide lower percentages of the DV also contribute to a healthful diet. For foods not listed in this table, please refer to the U.S. Department of Agriculture's Nutrient Database Web site: http://www.nal.usda.gov/fnic/cgi-bin/nut_search.pl.

What affects iron absorption?

Iron absorption refers to the amount of dietary iron that the body obtains and uses from food. Healthy adults absorb about 10% to 15% of dietary iron, but individual absorption is influenced by several factors [1,3,8,11-15].

Storage levels of iron have the greatest influence on iron absorption. Iron absorption increases when body stores are low. When iron stores are high, absorption decreases to help protect against toxic effects of iron overload [1,3]. Iron absorption is also influenced by the type of dietary iron consumed. Absorption of heme iron from meat proteins is efficient. Absorption of heme iron ranges from 15% to 35%, and is not significantly affected by diet [15]. In contrast, 2% to 20% of nonheme iron in plant foods such as rice, maize, black beans, soybeans and wheat is absorbed [16]. Nonheme iron absorption is significantly influenced by various food components [1,3,11-15].

Meat proteins and vitamin C will improve the absorption of nonheme iron [1,17-18]. Tannins (found in tea), calcium, polyphenols, and phytates (found in legumes and whole grains) can decrease absorption of nonheme iron [1,19-24]. Some proteins found in soybeans also inhibit nonheme iron absorption [1,25]. It is most important to include foods that enhance nonheme iron absorption when daily iron intake is less than recommended, when iron losses are high (which may occur with heavy menstrual losses), when iron requirements are high (as in pregnancy), and when only vegetarian nonheme sources of iron are consumed.

References

What is the recommended intake for iron?

Recommendations for iron are provided in the Dietary Reference Intakes (DRIs) developed by the Institute of Medicine of the National Academy of Sciences [1]. Dietary Reference Intakes is the general term for a set of reference values used for planning and assessing nutrient intake for healthy people. Three important types of reference values included in the DRIs are Recommended Dietary Allowances (RDA), Adequate Intakes (AI), and Tolerable Upper Intake Levels (UL). The RDA recommends the average daily intake that is sufficient to meet the nutrient requirements of nearly all (97-98%) healthy individuals in each age and gender group [1]. An AI is set when there is insufficient scientific data available to establish a RDA. AIs meet or exceed the amount needed to maintain a nutritional state of adequacy in nearly all members of a specific age and gender group. The UL, on the other hand, is the maximum daily intake unlikely to result in adverse health effects [1]. Table 3 lists the RDAs for iron, in milligrams, for infants, children and adults.

Table 3: Recommended Dietary Allowances for Iron for Infants (7 to 12 months), Children, and Adults [1]

Healthy full term infants are born with a supply of iron that lasts for 4 to 6 months. There is not enough evidence available to establish a RDA for iron for infants from birth through 6 months of age. Recommended iron intake for this age group is based on an Adequate Intake (AI) that reflects the average iron intake of healthy infants fed breast milk [1]. Table 4 lists the AI for iron, in milligrams, for infants up to 6 months of age.

Table 4: Adequate Intake for Iron for Infants (0 to 6 months) [1]

Iron in human breast milk is well absorbed by infants. It is estimated that infants can use greater than 50% of the iron in breast milk as compared to less than 12% of the iron in infant formula [1]. The amount of iron in cow's milk is low, and infants poorly absorb it. Feeding cow's milk to infants also may result in gastrointestinal bleeding. For these reasons, cow's milk should not be fed to infants until they are at least 1 year old [1]. The American Academy of Pediatrics (AAP) recommends that infants be exclusively breast fed for the first six months of life. Gradual introduction of iron-enriched solid foods should complement breast milk from 7 to 12 months of age [26]. Infants weaned from breast milk before 12 months of age should receive iron-fortified infant formula [26]. Infant formulas that contain from 4 to 12 milligrams of iron per liter are considered iron-fortified [27].

Data from the National Health and Nutrition Examination Survey (NHANES) describe dietary intake of Americans 2 months of age and older. NHANES (1988-94) data suggest that males of all racial and ethnic groups consume recommended amounts of iron. However, iron intakes are generally low in females of childbearing age and young children [28-29].

Researchers also examine specific groups within the NHANES population. For example, researchers have compared dietary intakes of adults who consider themselves to be food insufficient (and therefore have limited access to nutritionally adequate foods) to those who are food sufficient (and have easy access to food). Older adults from food insufficient families had significantly lower intakes of iron than older adults who are food sufficient. In one survey, twenty percent of adults age 20 to 59 and 13.6% of adults age 60 and older from food insufficient families consumed less than 50% of the RDA for iron, as compared to 13% of adults age 20 to 50 and 2.5% of adults age 60 and older from food sufficient families [30].

References

Iron intake is negatively influenced by low nutrient density foods, which are high in calories but low in vitamins and minerals. Sugar sweetened sodas and most desserts are examples of low nutrient density foods, as are snack foods such as potato chips. Among almost 5,000 children and adolescents between the ages of 8 and 18 who were surveyed, low nutrient density foods contributed almost 30% of daily caloric intake, with sweeteners and desserts jointly accounting for almost 25% of caloric intake. Those children and adolescents who consumed fewer "low nutrient density" foods were more likely to consume recommended amounts of iron [31].

Data from The Continuing Survey of Food Intakes by Individuals (CSFII1994-6 and 1998) was used to examine the effect of major food and beverage sources of added sugars on micronutrient intake of U.S. children aged 6 to 17 years. Researchers found that consumption of presweetened cereals, which are fortified with iron, increased the likelihood of meeting recommendations for iron intake. On the other hand, as intake of sugar-sweetened beverages, sugars, sweets, and sweetened grains increased, children were less likely to consume recommended amounts of iron [32].

When can iron deficiency occur?

The World Health Organization considers iron deficiency the number one nutritional disorder in the world [33]. As many as 80% of the world's population may be iron deficient, while 30% may have iron deficiency anemia [34].

Iron deficiency develops gradually and usually begins with a negative iron balance, when iron intake does not meet the daily need for dietary iron. This negative balance initially depletes the storage form of iron while the blood hemoglobin level, a marker of iron status, remains normal. Iron deficiency anemia is an advanced stage of iron depletion. It occurs when storage sites of iron are deficient and blood levels of iron cannot meet daily needs. Blood hemoglobin levels are below normal with iron deficiency anemia [1].

Iron deficiency anemia can be associated with low dietary intake of iron, inadequate absorption of iron, or excessive blood loss [1,16,35]. Women of childbearing age, pregnant women, preterm and low birth weight infants, older infants and toddlers, and teenage girls are at greatest risk of developing iron deficiency anemia because they have the greatest need for iron [33]. Women with heavy menstrual losses can lose a significant amount of iron and are at considerable risk for iron deficiency [1,3]. Adult men and post-menopausal women lose very little iron, and have a low risk of iron deficiency.

Individuals with kidney failure, especially those being treated with dialysis, are at high risk for developing iron deficiency anemia. This is because their kidneys cannot create enough erythropoietin, a hormone needed to make red blood cells. Both iron and erythropoietin can be lost during kidney dialysis. Individuals who receive routine dialysis treatments usually need extra iron and synthetic erythropoietin to prevent iron deficiency [36-38].

Vitamin A helps mobilize iron from its storage sites, so a deficiency of vitamin A limits the body's ability to use stored iron. This results in an "apparent" iron deficiency because hemoglobin levels are low even though the body can maintain normal amounts of stored iron [39-40]. While uncommon in the U.S., this problem is seen in developing countries where vitamin A deficiency often occurs.

Chronic malabsorption can contribute to iron depletion and deficiency by limiting dietary iron absorption or by contributing to intestinal blood loss. Most iron is absorbed in the small intestines. Gastrointestinal disorders that result in inflammation of the small intestine may result in diarrhea, poor absorption of dietary iron, and iron depletion [41].

Signs of iron deficiency anemia include [1,5-6,42]:

• feeling tired and weak
• decreased work and school performance
• slow cognitive and social development during childhood
• difficulty maintaining body temperature
• decreased immune function, which increases susceptibility to infection
• glossitis (an inflamed tongue)

Eating nonnutritive substances such as dirt and clay, often referred to as pica or geophagia, is sometimes seen in persons with iron deficiency. There is disagreement about the cause of this association. Some researchers believe that these eating abnormalities may result in an iron deficiency. Other researchers believe that iron deficiency may somehow increase the likelihood of these eating problems [43-44].

People with chronic infectious, inflammatory, or malignant disorders such as arthritis and cancer may become anemic. However, the anemia that occurs with inflammatory disorders differs from iron deficiency anemia and may not respond to iron supplements [45-47]. Research suggests that inflammation may over-activate a protein involved in iron metabolism. This protein may inhibit iron absorption and reduce the amount of iron circulating in blood, resulting in anemia [48].

References

Who may need extra iron to prevent a deficiency?

Three groups of people are most likely to benefit from iron supplements: people with a greater need for iron, individuals who tend to lose more iron, and people who do not absorb iron normally. These individuals include [1,36-38,41,49-57]:

• pregnant women
• preterm and low birth weight infants
• older infants and toddlers
• teenage girls
• women of childbearing age, especially those with heavy menstrual losses
• people with renal failure, especially those undergoing routine dialysis
• people with gastrointestinal disorders who do not absorb iron normally

Celiac Disease and Crohn's Syndrome are associated with gastrointestinal malabsorption and may impair iron absorption. Iron supplementation may be needed if these conditions result in iron deficiency anemia [41].

Women taking oral contraceptives may experience less bleeding during their periods and have a lower risk of developing an iron deficiency. Women who use an intrauterine device (IUD) to prevent pregnancy may experience more bleeding and have a greater risk of developing an iron deficiency. If laboratory tests indicate iron deficiency anemia, iron supplements may be recommended.

Total dietary iron intake in vegetarian diets may meet recommended levels; however that iron is less available for absorption than in diets that include meat [58]. Vegetarians who exclude all animal products from their diet may need almost twice as much dietary iron each day as non-vegetarians because of the lower intestinal absorption of nonheme iron in plant foods [1]. Vegetarians should consider consuming nonheme iron sources together with a good source of vitamin C, such as citrus fruits, to improve the absorption of nonheme iron [1].

There are many causes of anemia, including iron deficiency. There are also several potential causes of iron deficiency. After a thorough evaluation, physicians can diagnose the cause of anemia and prescribe the appropriate treatment.

Does pregnancy increase the need for iron?

Nutrient requirements increase during pregnancy to support fetal growth and maternal health. Iron requirements of pregnant women are approximately double that of non-pregnant women because of increased blood volume during pregnancy, increased needs of the fetus, and blood losses that occur during delivery [16]. If iron intake does not meet increased requirements, iron deficiency anemia can occur. Iron deficiency anemia of pregnancy is responsible for significant morbidity, such as premature deliveries and giving birth to infants with low birth weight [1,51,59-62].

Low levels of hemoglobin and hematocrit may indicate iron deficiency. Hemoglobin is the protein in red blood cells that carries oxygen to tissues. Hematocrit is the proportion of whole blood that is made up of red blood cells. Nutritionists estimate that over half of pregnant women in the world may have hemoglobin levels consistent with iron deficiency. In the U.S., the Centers for Disease Control (CDC) estimated that 12% of all women age 12 to 49 years were iron deficient in 1999-2000. When broken down by groups, 10% of non-Hispanic white women, 22% of Mexican-American women, and 19% of non-Hispanic black women were iron deficient. Prevalence of iron deficiency anemia among lower income pregnant women has remained the same, at about 30%, since the 1980s [63].

The RDA for iron for pregnant women increases to 27 mg per day. Unfortunately, data from the 1988-94 NHANES survey suggested that the median iron intake among pregnant women was approximately 15 mg per day [1]. When median iron intake is less than the RDA, more than half of the group consumes less iron than is recommended each day.

Several major health organizations recommend iron supplementation during pregnancy to help pregnant women meet their iron requirements. The CDC recommends routine low-dose iron supplementation (30 mg/day) for all pregnant women, beginning at the first prenatal visit [33]. When a low hemoglobin or hematocrit is confirmed by repeat testing, the CDC recommends larger doses of supplemental iron. The Institute of Medicine of the National Academy of Sciences also supports iron supplementation during pregnancy [1]. Obstetricians often monitor the need for iron supplementation during pregnancy and provide individualized recommendations to pregnant women.

References

Some facts about iron supplements

Iron supplementation is indicated when diet alone cannot restore deficient iron levels to normal within an acceptable timeframe. Supplements are especially important when an individual is experiencing clinical symptoms of iron deficiency anemia. The goals of providing oral iron supplements are to supply sufficient iron to restore normal storage levels of iron and to replenish hemoglobin deficits. When hemoglobin levels are below normal, physicians often measure serum ferritin, the storage form of iron. A serum ferritin level less than or equal to 15 micrograms per liter confirms iron deficiency anemia in women, and suggests a possible need for iron supplementation [33].

Supplemental iron is available in two forms: ferrous and ferric. Ferrous iron salts (ferrous fumarate, ferrous sulfate, and ferrous gluconate) are the best absorbed forms of iron supplements [64]. Elemental iron is the amount of iron in a supplement that is available for absorption. Figure 1 lists the percent elemental iron in these supplements.

Figure 1: Percent Elemental Iron in Iron Supplements [65]

The amount of iron absorbed decreases with increasing doses. For this reason, it is recommended that most people take their prescribed daily iron supplement in two or three equally spaced doses. For adults who are not pregnant, the CDC recommends taking 50 mg to 60 mg of oral elemental iron (the approximate amount of elemental iron in one 300 mg tablet of ferrous sulfate) twice daily for three months for the therapeutic treatment of iron deficiency anemia [33]. However, physicians evaluate each person individually, and prescribe according to individual needs.

Therapeutic doses of iron supplements, which are prescribed for iron deficiency anemia, may cause gastrointestinal side effects such as nausea, vomiting, constipation, diarrhea, dark colored stools, and/or abdominal distress [33]. Starting with half the recommended dose and gradually increasing to the full dose will help minimize these side effects. Taking the supplement in divided doses and with food also may help limit these symptoms. Iron from enteric coated or delayed-release preparations may have fewer side effects, but is not as well absorbed and not usually recommended [64].

Physicians monitor the effectiveness of iron supplements by measuring laboratory indices, including reticulocyte count (levels of newly formed red blood cells), hemoglobin levels, and ferritin levels. In the presence of anemia, reticulocyte counts will begin to rise after a few days of supplementation. Hemoglobin usually increases within 2 to 3 weeks of starting iron supplementation.

In rare situations parenteral iron (provided by injection or I.V.) is required. Doctors will carefully manage the administration of parenteral iron [66].

Who should be cautious about taking iron supplements?

Iron deficiency is uncommon among adult men and postmenopausal women. These individuals should only take iron supplements when prescribed by a physician because of their greater risk of iron overload. Iron overload is a condition in which excess iron is found in the blood and stored in organs such as the liver and heart. Iron overload is associated with several genetic diseases including hemochromatosis, which affects approximately 1 in 250 individuals of northern European descent [67]. Individuals with hemochromatosis absorb iron very efficiently, which can result in a build up of excess iron and can cause organ damage such as cirrhosis of the liver and heart failure [1,3,67-69]. Hemochromatosis is often not diagnosed until excess iron stores have damaged an organ. Iron supplementation may accelerate the effects of hemochromatosis, an important reason why adult men and postmenopausal women who are not iron deficient should avoid iron supplements. Individuals with blood disorders that require frequent blood transfusions are also at risk of iron overload and are usually advised to avoid iron supplements.

References

What are some current issues and controversies about iron?

Iron and heart disease:

Because known risk factors cannot explain all cases of heart disease, researchers continue to look for new causes. Some evidence suggests that iron can stimulate the activity of free radicals. Free radicals are natural by-products of oxygen metabolism that are associated with chronic diseases, including cardiovascular disease. Free radicals may inflame and damage coronary arteries, the blood vessels that supply the heart muscle. This inflammation may contribute to the development of atherosclerosis, a condition characterized by partial or complete blockage of one or more coronary arteries. Other researchers suggest that iron may contribute to the oxidation of LDL ("bad") cholesterol, changing it to a form that is more damaging to coronary arteries.

As far back as the 1980s, some researchers suggested that the regular menstrual loss of iron, rather than a protective effect from estrogen, could better explain the lower incidence of heart disease seen in pre-menopausal women [70]. After menopause, a woman's risk of developing coronary heart disease increases along with her iron stores. Researchers have also observed lower rates of heart disease in populations with lower iron stores, such as those in developing countries [71-74]. In those geographic areas, lower iron stores are attributed to low meat (and iron) intake, high fiber diets that inhibit iron absorption, and gastrointestinal (GI) blood (and iron) loss due to parasitic infections.

In the 1980s, researchers linked high iron stores with increased risk of heart attacks in Finnish men [75]. However, more recent studies have not supported such an association [76-77].

One way of testing an association between iron stores and coronary heart disease is to compare levels of ferritin, the storage form of iron, to the degree of atherosclerosis in coronary arteries. In one study, researchers examined the relationship between ferritin levels and atherosclerosis in 100 men and women referred for cardiac examination. In this population, higher ferritin levels were not associated with an increased degree of atherosclerosis, as measured by angiography. Coronary angiography is a technique used to estimate the degree of blockage in coronary arteries [78]. In a different study, researchers found that ferritin levels were higher in male patients diagnosed with coronary artery disease. They did not find any association between ferritin levels and risk of coronary disease in women [79].

A second way to test this association is to examine rates of coronary disease in people who frequently donate blood. If excess iron stores contribute to heart disease, frequent blood donation could potentially lower heart disease rates because of the iron loss associated with blood donation. Over 2,000 men over age 39 and women over age 50 who donated blood between 1988 and 1990 were surveyed 10 years later to compare rates of cardiac events to frequency of blood donation. Cardiac events were defined as (1) occurrence of an acute myocardial infarction (heart attack), (2) undergoing angioplasty, a medical procedure that opens a blocked coronary artery; or (3) undergoing bypass grafting, a surgical procedure that replaces blocked coronary arteries with healthy blood vessels. Researchers found that frequent donors, who donated more than 1 unit of whole blood each year between 1988 and 1990, were less likely to experience cardiac events than casual donors (those who only donated a single unit in that 3-year period). Researchers concluded that frequent and long-term blood donation may decrease the risk of cardiac events [80].

Conflicting results, and different methods to measure iron stores, make it difficult to reach a final conclusion on this issue. However, researchers know that it is feasible to decrease iron stores in healthy individual through phlebotomy (blood letting or donation). Using phlebotomy, researchers hope to learn more about iron levels and cardiovascular disease.

Iron and intense exercise:

Many men and women who engage in regular, intense exercise such as jogging, competitive swimming, and cycling have marginal or inadequate iron status [1,81-85]. Possible explanations include increased gastrointestinal blood loss after running and a greater turnover of red blood cells. Also, red blood cells within the foot can rupture while running. For these reasons, the need for iron may be 30% greater in those who engage in regular intense exercise [1].

Three groups of athletes may be at greatest risk of iron depletion and deficiency: female athletes, distance runners, and vegetarian athletes. It is particularly important for members of these groups to consume recommended amounts of iron and to pay attention to dietary factors that enhance iron absorption. If appropriate nutrition intervention does not promote normal iron status, iron supplementation may be indicated. In one study of female swimmers, researchers found that supplementation with 125 milligrams (mg) of ferrous sulfate per day prevented iron depletion. These swimmers maintained adequate iron stores, and did not experience the gastrointestinal side effects often seen with higher doses of iron supplementation [86].

Iron and mineral interactions

Some researchers have raised concerns about interactions between iron, zinc, and calcium. When iron and zinc supplements are given together in a water solution and without food, greater doses of iron may decrease zinc absorption. However, the effect of supplemental iron on zinc absorption does not appear to be significant when supplements are consumed with food [1,87-88]. There is evidence that calcium from supplements and dairy foods may inhibit iron absorption, but it has been very difficult to distinguish between the effects of calcium on iron absorption versus other inhibitory factors such as phytate [1].

References

What is the risk of iron toxicity?

There is considerable potential for iron toxicity because very little iron is excreted from the body. Thus, iron can accumulate in body tissues and organs when normal storage sites are full. For example, people with hemachromatosis are at risk of developing iron toxicity because of their high iron stores.

In children, death has occurred from ingesting 200 mg of iron [7]. It is important to keep iron supplements tightly capped and away from children's reach. Any time excessive iron intake is suspected, immediately call your physician or Poison Control Center, or visit your local emergency room. Doses of iron prescribed for iron deficiency anemia in adults are associated with constipation, nausea, vomiting, and diarrhea, especially when the supplements are taken on an empty stomach [1].

In 2001, the Institute of Medicine of the National Academy of Sciences set a tolerable upper intake level (UL) for iron for healthy people [1]. There may be times when a physician prescribes an intake higher than the upper limit, such as when individuals with iron deficiency anemia need higher doses to replenish their iron stores. Table 5 lists the ULs for healthy adults, children, and infants 7 to 12 months of age [1].

Table 5: Tolerable Upper Intake Levels for Iron for Infants 7 to 12 months, Children, and Adults [1]

Selecting a healthful diet

As the 2000 Dietary Guidelines for Americans states, "Different foods contain different nutrients and other healthful substances. No single food can supply all the nutrients in the amounts you need" [89]. Beef and turkey are good sources of heme iron while beans and lentils are high in nonheme iron. In addition, many foods, such as ready-to-eat cereals, are fortified with iron. It is important for anyone who is considering taking an iron supplement to first consider whether their needs are being met by natural dietary sources of heme and nonheme iron and foods fortified with iron, and to discuss their potential need for iron supplements with their physician. If you want more information about building a healthful diet, refer to the Dietary Guidelines for Americans http://www.usda.gov/cnpp/DietGd.pdf [89], and the U.S. Department of Agriculture's Food Guide Pyramid http://www.usda.gov/cnpp/DietGd.pdf [90].

back to: Alternative Medicine Home ~ Alternative Medicine Treatments

References

1. Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium and Zinc. Washington, DC: National Academy Press, 2001.
2. Dallman PR. Biochemical basis for the manifestations of iron deficiency. Annu Rev Nutr 1986;6:13-40. [PubMed abstract]
3. Bothwell TH, Charlton RW, Cook JD, Finch CA. Iron Metabolism in Man. St. Louis: Oxford: Blackwell Scientific, 1979.
4. Andrews NC. Disorders of iron metabolism. N Engl J Med 1999;341:1986-95. [PubMed abstract]
5. Haas JD, Brownlie T 4th. Iron deficiency and reduced work capacity: a critical review of the research to determine a causal relationship. J Nutr 2001;131:691S-6S. [PubMed abstract]
6. Bhaskaram P. Immunobiology of mild micronutrient deficiencies. Br J Nutr 2001;85:S75-80. [PubMed abstract]
7. Corbett JV. Accidental poisoning with iron supplements. MCN Am J Matern Child Nurs 1995;20:234. [PubMed abstract]
8. Miret S, Simpson RJ, McKie AT. Physiology and molecular biology of dietary iron absorption. Annu Rev Nutr 2003;23:283-301.
9. Hurrell RF. Preventing iron deficiency through food fortification. Nutr Rev 1997;55:210-22. [PubMed abstract]
10. U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA Nutrient Database for Standard Reference, Release 16. Nutrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/foodcomp.
11. Uzel C and Conrad ME. Absorption of heme iron. Semin Hematol 1998;35:27-34. [PubMed abstract]
12. Sandberg A. Bioavailability of minerals in legumes. British J of Nutrition. 2002;88:S281-5. [PubMed abstract]
13. Davidsson L. Approaches to improve iron bioavailability from complementary foods. J Nutr 2003;133:1560S-2S. [PubMed abstract]
14. Hallberg L, Hulten L, Gramatkovski E. Iron absorption from the whole diet in men: how effective is the regulation of iron absorption? Am J Clin Nutr 1997;66:347-56. [PubMed abstract]
15. Monson ER. Iron and absorption: dietary factors which impact iron bioavailability. J Am Dietet Assoc. 1988;88:786-90.
16. Tapiero H, Gate L, Tew KD. Iron: deficiencies and requirements. Biomed Pharmacother. 2001;55:324-32. [PubMed abstract]
17. Hunt JR, Gallagher SK, Johnson LK. Effect of ascorbic acid on apparent iron absorption by women with low iron stores. Am J Clin Nutr 1994;59:1381-5. [PubMed abstract]
18. Siegenberg D, Baynes RD, Bothwell TH, Macfarlane BJ, Lamparelli RD, Car NG, MacPhail P, Schmidt U, Tal A, Mayet F. Ascorbic acid prevents the dose-dependent inhibitory effects of polyphenols and phytates on nonheme-iron absorption. Am J Clin Nutr 1991;53:537-41. [PubMed abstract]
19. Samman S, Sandstrom B, Toft MB, Bukhave K, Jensen M, Sorensen SS, Hansen M. Green tea or rosemary extract added to foods reduces nonheme-iron absorption. Am J Clin Nutr 2001;73:607-12. [PubMed abstract]
20. Brune M, Rossander L, Hallberg L. Iron absorption and phenolic compounds: importance of different phenolic structures. Eur J Clin Nutr 1989;43:547-57. [PubMed abstract]
21. Hallberg L, Rossander-Hulthen L, Brune M, Gleerup A. Inhibition of haem-iron absorption in man by calcium. Br J Nutr 1993;69:533-40. [PubMed abstract]
22. Hallberg L, Brune M, Erlandsson M, Sandberg AS, Rossander-Hulten L. Calcium: effect of different amounts on nonheme- and heme-iron absorption in humans. Am J Clin Nutr 1991;53:112-9. [PubMed abstract]
23. Minihane AM, Fairweather-Tair SJ. Effect of calcium supplementation on daily nonheme-iron absorption and long-term iron status. Am J Clin Nutr 1998;68:96-102. [PubMed abstract]
24. Cook JD, Reddy MB, Burri J, Juillerat MA, Hurrell RF. The influence of different cereal grains on iron absorption from infant cereal foods. Am J Clin Nutr 1997;65:964-9. [PubMed abstract]
25. Lynch SR, Dassenko SA, Cook JD, Juillerat MA, Hurrell RF. Inhibitory effect of a soybean-protein-related moiety on iron absorption in humans. Am J Clin Nutr 1994;60:567-72. [PubMed abstract]
26. Breastfeeding and the use of human milk. American Academy of Pediatrics. Work Group on Breastfeeding. Pediatrics 1997;100:1035-9. [PubMed abstract]
27. 27 American Academy of Pediatrics: Committee on Nutrition. Iron fortification of infant formulas. Pediatrics 1999;104:119-23. [PubMed abstract]
28. Bialostosky K, Wright JD, Kennedy-Stephenson J, McDowell M, Johnson CL. Dietary intake of macronutrients, micronutrients and other dietary constituents: United States 1988-94. Vital Heath Stat. 11(245) ed: National Center for Health Statistics, 2002:168. [PubMed abstract]
29. Interagency Board for Nutrition Monitoring and Related Research. Third Report on Nutrition Monitoring in the United States. Washington, DC: U.S. Government Printing Office, J Nutr. 1996;126:iii-x: 1907S-36S.
30. Dixon LB, Winkleby MA, Radimer KL. Dietary intakes and serum nutrients differ between adults from food insufficient and food sufficient families: Third National Health and Nutrition Examination. J Nutr 2001;131:1232-46. [PubMed abstract]
31. Kant A. Reported consumption of low-nutrient-density foods by American children and adolescents. Arch Pediatr Aolesc Med 1993;157:789-96
32. Frary CD, Johnson RK, Wang MQ. Children and adolescents' choice of foods and beverages high in added sugars are associated with intakes of key nutrients and food groups. J Adolesc Health 2004;34:56-63. [PubMed abstract]
33. CDC Recommendations to prevent and control iron deficiency in the United States. Centers for Disease Control and Prevention. MMWR Recomm Rep 1998;47:1-29.
34. Stoltzfus RJ. Defining iron-deficiency anemia in public health terms: reexamining the nature and magnitude of the public health problem. J Nutr 2001;131:565S-7S.
35. Hallberg L. Prevention of iron deficiency. Baillieres Clin Haematol 1994;7:805-14. [PubMed abstract]
36. Nissenson AR, Strobos J. Iron deficiency in patients with renal failure. Kidney Int Suppl 1999;69:S18-21. [PubMed abstract]
37. Fishbane S, Mittal SK, Maesaka JK. Beneficial effects of iron therapy in renal failure patients on hemodialysis. Kidney Int Suppl 1999;69:S67-70. [PubMed abstract]
38. Drueke TB, Barany P, Cazzola M, Eschbach JW, Grutzmacher P, Kaltwasser JP, MacDougall IC, Pippard MJ, Shaldon S, van Wyck D. Management of iron deficiency in renal anemia: guidelines for the optimal therapeutic approach in erythropoietin-treated patients. Clin Nephrol 1997;48:1-8. [PubMed abstract]
39. Kolsteren P, Rahman SR, Hilderbrand K, Diniz A. Treatment for iron deficiency anaemia with a combined supplementation of iron, vitamin A and zinc in women of Dinajpur, Bangladesh. Eur J Clin Nutr 1999;53:102-6. [PubMed abstract]
40. van Stuijvenberg ME, Kruger M, Badenhorst CJ, Mansvelt EP, Laubscher JA. Response to an iron fortification programme in relation to vitamin A status in 6-12-year-old school children. Int J Food Sci Nutr 1997;48:41-9. [PubMed abstract]
41. Annibale B, Capurso G, Chistolini A, D'Ambra G, DiGiulio E, Monarca B, DelleFave G. Gastrointestinal causes of refractory iron deficiency anemia in patients without gastrointestinal symptoms. Am J Med 2001;111:439-45. [PubMed abstract]
42. Allen LH, Iron supplements: scientific issues concerning efficacy and implications for research and programs. J Nutr 2002;132:813S-9S. [PubMed abstract]
43. Rose EA, Porcerelli JH, Neale AV. Pica: common but commonly missed. J Am Board Fam Pract 2000;13:353-8. [PubMed abstract]
44. Singhi S, Ravishanker R, Singhi P, Nath R. Low plasma zinc and iron in pica. Indian J Pediatr 2003;70:139-43. [PubMed abstract]
45. Jurado RL. Iron, infections, and anemia of inflammation. Clin Infect Dis 1997;25:888-95. [PubMed abstract]
46. Abramson SD, Abramson N. 'Common' uncommon anemias. Am Fam Physician 1999;59:851-8. [PubMed abstract]
47. Spivak JL. Iron and the anemia of chronic disease. Oncology (Huntingt) 2002;16:25-33. [PubMed abstract]
48. Leong W and Lonnerdal B. Hepcidin, the recently identified peptide that appears to regulate iron absorption. J Nutr 2004;134:1-4. [PubMed abstract]
49. Picciano MF. Pregnancy and lactation: physiological adjustments, nutritional requirements and the role of dietary supplements. J Nutr 2003;133:1997S-2002S. [PubMed abstract]
50. Blot I, Diallo D, Tchernia G. Iron deficiency in pregnancy: effects on the newborn. Curr Opin Hematol 1999;6:65-70. [PubMed abstract]
51. Cogswell ME, Parvanta I, Ickes L, Yip R, Brittenham GM. Iron supplementation during pregnancy, anemia, and birth weight: a randomized controlled trial. Am J Clin Nutr 2003;78:773-81. [PubMed abstract]
52. Idjradinata P, Pollitt E. Reversal of developmental delays in iron-deficient anaemic infants treated with iron. Lancet 1993;341:1-4. [PubMed abstract]
53. Bodnar LM, Cogswell ME, Scanlon KS. Low income postpartum women are at risk of iron deficiency. J Nutr 2002;132:2298-302. [PubMed abstract]
54. Looker AC, Dallman PR, Carroll MD, Gunter EW, Johnson CL. Prevalence of iron deficiency in the United States. J Am Med Assoc 1997;277:973-6. [PubMed abstract]
55. American Academy of Pediatrics Committee on Nutrition 2003-2004. Pediatric Nutrition Handbook, 5th edition. 2004. Ch 19: Iron Deficiency. p 299-312.
56. Bickford AK. Evaluation and treatment of iron deficiency in patients with kidney disease. Nutr Clin Care 2002;5:225-30. [PubMed abstract]
57. Canavese C, Bergamo D, Ciccone G, Burdese M, Maddalena E, Barbieri S, Thea A, Fop F. Low-dose continuous iron therapy leads to a positive iron balance and decreased serum transferrin levels. Nephrol Dial Transplant 2004;19:1564-70. [PubMed abstract]
58. Hunt JR. Bioavailability of iron, zinc, and other trace minerals from vegetarian diets. Am J Clin Nutr 2003;78:633S-9S. [PubMed abstract]
59. Blot I, Diallo D, Tchernia G. Iron deficiency in pregnancy: effects on the newborn. Curr Opin Hematol 1999;6:65-70. [PubMed abstract]
60. Malhotra M, Sharma JB, Batra S, Sharma S, Murthy NS, Arora R. Maternal and perinatal outcome in varying degrees of anemia. Int J Gynaecol Obstet 2002;79:93-100. [PubMed abstract]
61. Allen LH. Pregnancy and iron deficiency: unresolved issues. Nutr Rev 1997;55:91-101. [PubMed abstract]
62. Iron deficiency anemia: recommended guidelines for the prevention, detection, and management among U.S. children and women of childbearing age. Washington, DC: Institute of Medicine. Food and Nutrition Board.National Academy Press, 1993.
63. Cogswell ME, Kettel-Khan L, Ramakrishnan U. Iron supplement use among women in the United States: science, policy and practice. J Nutr 2003:133:1974S-7S. [PubMed abstract]
64. Hoffman R, Benz E, Shattil S, Furie B, Cohen H, Silberstein L, McGlave P. Hematology: Basic Principles and Practice, 3rd ed. ch 26: Disorders of Iron Metabolism: Iron deficiency and overload. Churchill Livingstone, Harcourt Brace & Co, New York, 2000.
65. Drug Facts and Comparisons. St. Louis: Facts and Comparisons, 2004.
66. Kumpf VJ. Parenteral iron supplementation. Nutr Clin Pract 1996;11:139-46. [PubMed abstract]
67. Burke W, Cogswell ME, McDonnell SM, Franks A. Public Health Strategies to Prevent the Complications of Hemochromatosis. Genetics and Public Health in the 21st Centry: using genetic information to improve health and prevent disease. Oxford University Press, 2000.
68. Bothwell TH, MacPhail AP. Hereditary hemochromatosis: etiologic, pathologic, and clinical aspects. Semin Hematol 1998;35:55-71. [PubMed abstract]
69. Brittenham GM. New advances in iron metabolism, iron deficiency, and iron overload. Curr Opin Hematol 1994;1:101-6. [PubMed abstract]
70. Sullivan JL. Iron versus cholesterol--perspectives on the iron and heart disease debate. J Clin Epidemiol 1996;49:1345-52. [PubMed abstract]
71. Weintraub WS, Wenger NK, Parthasarathy S, Brown WV. Hyperlipidemia versus iron overload and coronary artery disease: yet more arguments on the cholesterol debate. J Clin Epidemiol 1996;49:1353-8. [PubMed abstract]
72. Sullivan JL. Iron versus cholesterol--response to dissent by Weintraub et al. J Clin Epidemiol 1996;49:1359-62. [PubMed abstract]
73. Sullivan JL. Iron therapy and cardiovascular disease. Kidney Int Suppl 1999;69:S135-7. [PubMed abstract]
74. Salonen JT, Nyyssonen K, Korpela H, Tuomilehto J, Seppanen R, Salonen R. High stored iron levels are associated with excess risk of myocardial infarction in eastern Finnish men. Circulation 1992;86:803-11. [PubMed abstract]
75. Sempos CT, Looker AC, Gillum RF, Makuc DM. Body iron stores and the risk of coronary heart disease. N Engl J Med 1994;330:1119-24. [PubMed abstract]
76. Danesh J, Appleby P. Coronary heart disease and iron status: meta-analyses of prospective studies. Circulation 1999;99:852-4. [PubMed abstract]
77. Ma J, Stampfer MJ. Body iron stores and coronary heart disease. Clin Chem 2002;48:601-3. [PubMed abstract]
78. Auer J, Rammer M, Berent R, Weber T, Lassnig E, Eber B. Body iron stores and coronary atherosclerosis assessed by coronary angiography. Nutr Metab Cardiovasc Dis 2002;12:285-90. [PubMed abstract]
79. Zacharski LR, Chow B, Lavori PW, Howes P, Bell M, DiTommaso M, Carnegie N, Bech F, Amidi M, Muluk S. The iron (Fe) and atherosclerosis study (FeAST): A pilot study of reduction of body iron stores in atherosclerotic peripheral vascular disease. Am Heart J 2000;139:337-45. [PubMed abstract]
80. Meyers DG, Jensen KC, Menitove JE. A historical cohort study of the effect of lowering body iron through blood donation on incident cardiac events. Transfusion. 2002;42:1135-9. [PubMed abstract]
81. Clarkson PM and Haymes EM. Exercise and mineral status of athletes: calcium, magnesium, phosphorus, and iron. Med Sci Sports Exerc 1995;27:831-43. [PubMed abstract]
82. Raunikar RA, Sabio H. Anemia in the adolescent athlete. Am J Dis Child 1992;146:1201-5. [PubMed abstract]
83. Lampe JW, Slavin JL, Apple FS. Iron status of active women and the effect of running a marathon on bowel function and gastrointestinal blood loss. Int J Sports Med 1991;12:173-9. [PubMed abstract]
84. Fogelholm M. Inadequate iron status in athletes: An exaggerated problem? Sports Nutrition: Minerals and Electrolytes. Boca Raton: CRC Press, 1995:81-95.
85. Beard J and Tobin B. Iron status and exercise. Am J Clin Nutr 2000:72:594S-7S. [PubMed abstract]
86. Brigham DE, Beard JL, Krimmel RS, Kenney WL. Changes in iron status during competitive season in female collegiate swimmers. Nutrition 1993;9:418-22. [PubMed abstract]
87. Whittaker P. Iron and zinc interactions in humans. Am J Clin Nutr 1998;68:442S-6S. [PubMed abstract]
88. Davidsson L, Almgren A, Sandstrom B, Hurrell RF. Zinc absorption in adult humans: the effect of iron fortification. Br J Nutr 1995;74:417-25. [PubMed abstract]
89. U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans. 5th ed. USDA Home and Garden Bulleting No. 232, Washington, DC: USDA, 2000. http://www.cnpp.usda.gov/DietaryGuidelines.htm
90. Center for Nutrition Policy and Promotion. United States Department of Agriculture. Food Guide Pyramid, 1992 (slightly revised 1996). http://www.nal.usda.gov/fnic/Fpyr/pyramid.htmll

Disclaimer

Reasonable care has been taken in preparing this document and the information provided herein is believed to be accurate. However, this information is not intended to constitute an "authoritative statement" under Food and Drug Administration rules and regulations.

About ODS and the NIH Clinical Center

The mission of the Office of Dietary Supplements (ODS) is to strengthen knowledge and understanding of dietary supplements by evaluating scientific information, stimulating and supporting research, disseminating research results, and educating the public to foster an enhanced quality of life and health for the U.S. population.

The NIH Clinical Center is the clinical research hospital for NIH. Through clinical research, physicians and scientist translate laboratory discoveries into better treatments, therapies and interventions to improve the nation's health.

General Safety Advisory

Health professionals and consumers need credible information to make thoughtful decisions about eating a healthful diet and using vitamin and mineral supplements. To help guide those decisions, registered dietitians at the NIH Clinical Center developed a series of Fact Sheets in conjunction with ODS. These Fact Sheets provide responsible information about the role of vitamins and minerals in health and disease. Each Fact Sheet in this series received extensive review by recognized experts from the academic and research communities.

The information is not intended to be a substitute for professional medical advice. It is important to seek the advice of a physician about any medical condition or symptom. It is also important to seek the advice of a physician, registered dietitian, pharmacist, or other qualified health professional about the appropriateness of taking dietary supplements and their potential interactions with medications.

back to: Alternative Medicine Home ~ Alternative Medicine Treatments

Detailed information about magnesium, the foods that provide magnesium, magnesium deficiency, and the best way to get extra magnesium.

Table of Contents

• Magnesium: What is it?
• What foods provide magnesium?
• What are the Dietary Reference Intakes for magnesium?
• When can magnesium deficiency occur?
• Who may need extra magnesium?
• What is the best way to get extra magnesium?
• What are some current issues and controversies about magnesium?
• What is the health risk of too much magnesium?
• Selecting a healthful diet
• References

Magnesium: What is it?

Magnesium is the fourth most abundant mineral in the body and is essential to good health. Approximately 50% of total body magnesium is found in bone. The other half is found predominantly inside cells of body tissues and organs. Only 1% of magnesium is found in blood, but the body works very hard to keep blood levels of magnesium constant [1].

Magnesium is needed for more than 300 biochemical reactions in the body. It helps maintain normal muscle and nerve function, keeps heart rhythm steady, supports a healthy immune system, and keeps bones strong. Magnesium also helps regulate blood sugar levels, promotes normal blood pressure, and is known to be involved in energy metabolism and protein synthesis [2-3]. There is an increased interest in the role of magnesium in preventing and managing disorders such as hypertension, cardiovascular disease, and diabetes. Dietary magnesium is absorbed in the small intestines. Magnesium is excreted through the kidneys [1-3,4].

What foods provide magnesium?

Green vegetables such as spinach are good sources of magnesium because the center of the chlorophyll molecule (which gives green vegetables their color) contains magnesium. Some legumes (beans and peas), nuts and seeds, and whole, unrefined grains are also good sources of magnesium [5]. Refined grains are generally low in magnesium [4-5]. When white flour is refined and processed, the magnesium-rich germ and bran are removed. Bread made from whole grain wheat flour provides more magnesium than bread made from white refined flour. Tap water can be a source of magnesium, but the amount varies according to the water supply. Water that naturally contains more minerals is described as "hard". "Hard" water contains more magnesium than "soft" water.

Eating a wide variety of legumes, nuts, whole grains, and vegetables will help you meet your daily dietary need for magnesium. Selected food sources of magnesium are listed in Table 1.

References

Table 1: Selected food sources of magnesium [5]

*DV = Daily Value. DVs are reference numbers developed by the Food and Drug Administration (FDA) to help consumers determine if a food contains a lot or a little of a specific nutrient. The DV for magnesium is 400 milligrams (mg). Most food labels do not list a food's magnesium content. The percent DV (%DV) listed on the table above indicates the percentage of the DV provided in one serving. A food providing 5% of the DV or less per serving is a low source while a food that provides 10-19% of the DV is a good source. A food that provides 20% or more of the DV is high in that nutrient. It is important to remember that foods that provide lower percentages of the DV also contribute to a healthful diet. For foods not listed in this table, please refer to the U.S. Department of Agriculture's Nutrient Database Web site: http://www.nal.usda.gov/fnic/cgi-bin/nut_search.pl.

References

What are the Dietary Reference Intakes for magnesium?

Recommendations for magnesium are provided in the Dietary Reference Intakes (DRIs) developed by the Institute of Medicine of the National Academy of Sciences [4]. Dietary Reference Intakes is the general term for a set of reference values used for planning and assessing nutrient intake for healthy people. Three important types of reference values included in the DRIs are Recommended Dietary Allowances (RDA), Adequate Intakes (AI), and Tolerable Upper Intake Levels (UL). The RDA recommends the average daily intake that is sufficient to meet the nutrient requirements of nearly all (97-98%) healthy individuals in each age and gender group. An AI is set when there is insufficient scientific data available to establish a RDA for specific age/gender groups. AIs meet or exceed the amount needed to maintain a nutritional state of adequacy in nearly all members of a specific age and gender group. The UL, on the other hand, is the maximum daily intake unlikely to result in adverse health effects. Table 2 lists the RDAs for magnesium, in milligrams, for children and adults [4].

Table 2: Recommended Dietary Allowances for magnesium for children and adults [4]

There is insufficient information on magnesium to establish a RDA for infants. For infants 0 to 12 months, the DRI is in the form of an Adequate Intake (AI), which is the mean intake of magnesium in healthy, breastfed infants. Table 3 lists the AIs for infants in milligrams (mg) [4].

Table 3: Recommended Adequate Intake for magnesium for infants [4]

Data from the 1999-2000 National Health and Nutrition Examination Survey suggest that substantial numbers of adults in the United States (US) fail to consume recommended amounts of magnesium. Among adult men and women, Caucasians consume significantly more magnesium than African-Americans. Magnesium intake is lower among older adults in every racial and ethnic group. African-American men and Caucasian men and women who take dietary supplements consume significantly more magnesium than those who do not [6].

When can magnesium deficiency occur?

Even though dietary surveys suggest that many Americans do not consume recommended amounts of magnesium, symptoms of magnesium deficiency are rarely seen in the US. However, there is concern about the prevalence of sub-optimal magnesium stores in the body. For many people, dietary intake may not be high enough to promote an optimal magnesium status, which may be protective against disorders such as cardiovascular disease and immune dysfunction [7-8].

The health status of the digestive system and the kidneys significantly influence magnesium status. Magnesium is absorbed in the intestines and then transported through the blood to cells and tissues. Approximately one-third to one-half of dietary magnesium is absorbed into the body [9-10]. Gastrointestinal disorders that impair absorption such as Crohn's disease can limit the body's ability to absorb magnesium. These disorders can deplete the body's stores of magnesium and in extreme cases may result in magnesium deficiency. Chronic or excessive vomiting and diarrhea may also result in magnesium depletion [1,10].

Healthy kidneys are able to limit urinary excretion of magnesium to compensate for low dietary intake. However, excessive loss of magnesium in urine can be a side effect of some medications and can also occur in cases of poorly-controlled diabetes and alcohol abuse [11-18].

Early signs of magnesium deficiency include loss of appetite, nausea, vomiting, fatigue, and weakness. As magnesium deficiency worsens, numbness, tingling, muscle contractions and cramps, seizures, personality changes, abnormal heart rhythms, and coronary spasms can occur [1,3-4]. Severe magnesium deficiency can result in low levels of calcium in the blood (hypocalcemia). Magnesium deficiency is also associated with low levels of potassium in the blood (hypokalemia) [1,19-20].

Many of these symptoms are general and can result from a variety of medical conditions other than magnesium deficiency. It is important to have a physician evaluate health complaints and problems so that appropriate care can be given.

References

Who may need extra magnesium?

Magnesium supplementation may be indicated when a specific health problem or condition causes an excessive loss of magnesium or limits magnesium absorption [2,7,9-11].

• Some medicines may result in magnesium deficiency, including certain diuretics, antibiotics, and medications used to treat cancer (anti-neoplastic medication) [12,14,19]. Examples of these medications are:

  • Diuretics: Lasix, Bumex, Edecrin, and hydrochlorothiazide

  • Antibiotics: Gentamicin, and Amphotericin

  • Anti-neoplastic medication: Cisplatin

• Individuals with poorly-controlled diabetes may benefit from magnesium supplements because of increased magnesium loss in urine associated with hyperglycemia [21].

• Magnesium supplementation may be indicated for persons with alcoholism. Low blood levels of magnesium occur in 30% to 60% of alcoholics, and in nearly 90% of patients experiencing alcohol withdrawal [17-18]. Anyone who substitutes alcohol for food will usually have significantly lower magnesium intakes.

• Individuals with chronic malabsorptive problems such as Crohn's disease, gluten sensitive enteropathy, regional enteritis, and intestinal surgery may lose magnesium through diarrhea and fat malabsorption [22]. Individuals with these conditions may need supplemental magnesium.

• Individuals with chronically low blood levels of potassium and calcium may have an underlying problem with magnesium deficiency. Magnesium supplements may help correct the potassium and calcium deficiencies [19].

• Older adults are at increased risk for magnesium deficiency. The 1999-2000 and 1998-94 National Health and Nutrition Examination Surveys suggest that older adults have lower dietary intakes of magnesium than younger adults [6,23]. In addition, magnesium absorption decreases and renal excretion of magnesium increases in older adults [4]. Seniors are also more likely to be taking drugs that interact with magnesium. This combination of factors places older adults at risk for magnesium deficiency [4]. It is very important for older adults to consume recommended amounts of dietary magnesium.

Doctors can evaluate magnesium status when above-mentioned medical problems occur, and determine the need for magnesium supplementation.

Table 4 describes some important interactions between certain drugs and magnesium. These interactions may result in higher or lower levels of magnesium, or may influence absorption of the medication.

Table 4: Common and important magnesium/drug interactions

References

What is the best way to get extra magnesium?

Eating a variety of whole grains, legumes, and vegetables (especially dark-green, leafy vegetables) every day will help provide recommended intakes of magnesium and maintain normal storage levels of this mineral. Increasing dietary intake of magnesium can often restore mildly depleted magnesium levels. However, increasing dietary intake of magnesium may not be enough to restore very low magnesium levels to normal.

When blood levels of magnesium are very low, intravenous (i.e. by IV) magnesium replacement is usually recommended. Magnesium tablets also may be prescribed, although some forms can cause diarrhea [27]. It is important to have the cause, severity, and consequences of low blood levels of magnesium evaluated by a physician, who can recommend the best way to restore magnesium levels to normal. Because people with kidney disease may not be able to excrete excess amounts of magnesium, they should not consume magnesium supplements unless prescribed by a physician.

Oral magnesium supplements combine magnesium with another substance such as a salt. Examples of magnesium supplements include magnesium oxide, magnesium sulfate, and magnesium carbonate. Elemental magnesium refers to the amount of magnesium in each compound. Figure 1 compares the amount of elemental magnesium in different types of magnesium supplements [28]. The amount of elemental magnesium in a compound and its bioavailability influence the effectiveness of the magnesium supplement. Bioavailability refers to the amount of magnesium in food, medications, and supplements that is absorbed in the intestines and ultimately available for biological activity in your cells and tissues. Enteric coating of a magnesium compound can decrease bioavailability [29]. In a study that compared four forms of magnesium preparations, results suggested lower bioavailability of magnesium oxide, with significantly higher and equal absorption and bioavailability of magnesium chloride and magnesium lactate [30]. This supports the belief that both the magnesium content of a dietary supplement and its bioavailability contribute to its ability to replete deficient levels of magnesium.

The information in Figure 1 is provided to demonstrate the variable amount of magnesium in magnesium supplements.

What are some current issues and controversies about magnesium?

Magnesium and blood pressure
"Epidemiologic evidence suggests that magnesium may play an important role in regulating blood pressure [4]." Diets that provide plenty of fruits and vegetables, which are good sources of potassium and magnesium, are consistently associated with lower blood pressure [31-33]. The DASH study (Dietary Approaches to Stop Hypertension), a human clinical trial, suggested that high blood pressure could be significantly lowered by a diet that emphasizes fruits, vegetables, and low fat dairy foods. Such a diet will be high in magnesium, potassium, and calcium, and low in sodium and fat [34-36].

An observational study examined the effect of various nutritional factors on incidence of high blood pressure in over 30,000 US male health professionals. After four years of follow-up, it was found that a lower risk of hypertension was associated with dietary patterns that provided more magnesium, potassium, and dietary fiber [37]. For 6 years, the Atherosclerosis Risk in Communities (ARIC) Study followed approximately 8,000 men and women who were initially free of hypertension. In this study, the risk of developing hypertension decreased as dietary magnesium intake increased in women, but not in men [38].

Foods high in magnesium are frequently high in potassium and dietary fiber. This makes it difficult to evaluate the independent effect of magnesium on blood pressure. However, newer scientific evidence from DASH clinical trials is strong enough that the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure states that diets that provide plenty of magnesium are positive lifestyle modifications for individuals with hypertension. This group recommends the DASH diet as a beneficial eating plan for people with hypertension and for those with "prehypertension" who desire to prevent high blood pressure http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/ [39-41].

References

Magnesium and diabetes
Diabetes is a disease resulting in insufficient production and/or inefficient use of insulin. Insulin is a hormone made by the pancreas. Insulin helps convert sugar and starches in food into energy to sustain life. There are two types of diabetes: type 1 and type 2. Type 1 diabetes is most often diagnosed in children and adolescents, and results from the body's inability to make insulin. Type 2 diabetes, which is sometimes referred to as adult-onset diabetes, is the most common form of diabetes. It is usually seen in adults and is most often associated with an inability to use the insulin made by the pancreas. Obesity is a risk factor for developing type 2 diabetes. In recent years, rates of type 2 diabetes have increased along with the rising rates of obesity.

Magnesium plays an important role in carbohydrate metabolism. It may influence the release and activity of insulin, the hormone that helps control blood glucose (sugar) levels [13]. Low blood levels of magnesium (hypomagnesemia) are frequently seen in individuals with type 2 diabetes. Hypomagnesemia may worsen insulin resistance, a condition that often precedes diabetes, or may be a consequence of insulin resistance. Individuals with insulin resistance do not use insulin efficiently and require greater amounts of insulin to maintain blood sugar within normal levels. The kidneys possibly lose their ability to retain magnesium during periods of severe hyperglycemia (significantly elevated blood glucose). The increased loss of magnesium in urine may then result in lower blood levels of magnesium [4]. In older adults, correcting magnesium depletion may improve insulin response and action [42].

The Nurses' Health Study (NHS) and the Health Professionals' Follow-up Study (HFS) follow more than 170,000 health professionals through biennial questionnaires. Diet was first evaluated in 1980 in the NHS and in 1986 in the HFS, and dietary assessments have been completed every 2 to 4 years since. Information on the use of dietary supplements, including multivitamins, is also collected. As part of these studies, over 127,000 research subjects (85,060 women and 42,872 men) with no history of diabetes, cardiovascular disease, or cancer at baseline were followed to examine risk factors for developing type 2 diabetes. Women were followed for 18 years; men were followed for 12 years. Over time, the risk for developing type 2 diabetes was greater in men and women with a lower magnesium intake. This study supports the dietary recommendation to increase consumption of major food sources of magnesium, such as whole grains, nuts, and green leafy vegetables [43].

The Iowa Women's Health Study has followed a group of older women since 1986. Researchers from this study examined the association between women's risk of developing type 2 diabetes and intake of carbohydrates, dietary fiber, and dietary magnesium. Dietary intake was estimated by a food frequency questionnaire, and incidence of diabetes throughout 6 years of follow-up was determined by asking participants if they had been diagnosed by a doctor as having diabetes. Based on baseline dietary intake assessment only, researchers' findings suggested that a greater intake of whole grains, dietary fiber, and magnesium decreased the risk of developing diabetes in older women [44].

The Women's Health Study was originally designed to evaluate the benefits versus risks of low-dose aspirin and vitamin E supplementation in the primary prevention of cardiovascular disease and cancer in women 45 years of age and older. In an examination of almost 40,000 women participating in this study, researchers also examined the association between magnesium intake and incidence of type 2 diabetes over an average of 6 years. Among women who were overweight, the risk of developing type 2 diabetes was significantly greater among those with lower magnesium intake [45]. This study also supports the dietary recommendation to increase consumption of major food sources of magnesium, such as whole grains, nuts, and green leafy vegetables.

On the other hand, the Atherosclerosis Risk in Communities (ARIC) study did not find any association between dietary magnesium intake and the risk for type 2 diabetes. During 6 years of follow-up, ARIC researchers examined the risk for type 2 diabetes in over 12,000 middle-aged adults without diabetes at baseline examination. In this study, there was no statistical association between dietary magnesium intake and incidence of type 2 diabetes in either black or white research subjects [46]. It can be confusing to read about studies that examine the same issue but have different results. Before reaching a conclusion on a health issue, scientists conduct and evaluate many studies. Over time, they determine when results are consistent enough to suggest a conclusion. They want to be sure they are providing correct recommendations to the public.

Several clinical studies have examined the potential benefit of supplemental magnesium on metabolic control of type 2 diabetes. In one such study, 63 subjects with below normal serum magnesium levels received either 2.5 grams of oral magnesium chloride daily "in liquid form" (providing 300 mg elemental magnesium per day) or a placebo. At the end of the 16-week study period, those who received the magnesium supplement had higher blood levels of magnesium and improved metabolic control of diabetes, as suggested by lower Hemoglobin A1C levels, than those who received a placebo [47]. Hemoglobin A1C is a test that measures overall control of blood glucose over the previous 2 to 3 months, and is considered by many doctors to be the single most important blood test for diabetics.

In another study, 128 patients with poorly controlled type 2 diabetes were randomized to receive a placebo or a supplement with either 500 mg or 1000 mg of magnesium oxide (MgO) for 30 days. All patients were also treated with diet or diet plus oral medication to control blood glucose levels. Magnesium levels increased in the group receiving 1000 mg magnesium oxide per day (equal to 600 mg elemental magnesium per day) but did not significantly change in the placebo group or the group receiving 500 mg of magnesium oxide per day (equal to 300 mg elemental magnesium per day). However, neither level of magnesium supplementation significantly improved blood glucose control [48].

References

These studies provide intriguing results but also suggest that additional research is needed to better explain the association between blood magnesium levels, dietary magnesium intake, and type 2 diabetes. In 1999, the American Diabetes Association (ADA) issued nutrition recommendations for diabetics stating that "...routine evaluation of blood magnesium level is recommended only in patients at high risk for magnesium deficiency. Levels of magnesium should be repleted (replaced) only if hypomagnesemia can be demonstrated" [21].

Magnesium and cardiovascular disease
Magnesium metabolism is very important to insulin sensitivity and blood pressure regulation, and magnesium deficiency is common in individuals with diabetes. The observed associations between magnesium metabolism, diabetes, and high blood pressure increase the likelihood that magnesium metabolism may influence cardiovascular disease [49].

Some observational surveys have associated higher blood levels of magnesium with lower risk of coronary heart disease [50-51]. In addition, some dietary surveys have suggested that a higher magnesium intake may reduce the risk of having a stroke [52]. There is also evidence that low body stores of magnesium increase the risk of abnormal heart rhythms, which may increase the risk of complications after a heart attack [4]. These studies suggest that consuming recommended amounts of magnesium may be beneficial to the cardiovascular system. They have also prompted interest in clinical trials to determine the effect of magnesium supplements on cardiovascular disease.

Several small studies suggest that magnesium supplementation may improve clinical outcomes in individuals with coronary disease. In one of these studies, the effect of magnesium supplementation on exercise tolerance, exercise-induced chest pain, and quality of life was examined in 187 patients. Patients received either a placebo or a supplement providing 365 milligrams of magnesium citrate twice daily for 6 months. At the end of the study period researchers found that magnesium therapy significantly increased magnesium levels. Patients receiving magnesium had a 14 percent improvement in exercise duration as compared to no change in the placebo group. Those receiving magnesium were also less likely to experience exercise-induced chest pain [53].

In another study, 50 men and women with stable coronary disease were randomized to receive either a placebo or a magnesium supplement that provided 342 mg magnesium oxide twice daily. After 6 months, those who received the oral magnesium supplement were found to have improved exercise tolerance [54].

In a third study, researchers examined whether magnesium supplementation would add to the anti-thrombotic (anti-clotting) effects of aspirin in 42 coronary patients [55]. For three months, each patient received either a placebo or a supplement with 400 mg of magnesium oxide two to three times daily. After a four-week break without any treatment, treatment groups were reversed so that each person in the study then received the alternate treatment for three months. Researchers found that supplemental magnesium did provide an additional anti-thrombotic effect.

These studies are encouraging, but involved small numbers. Additional studies are needed to better understand the complex relationships between magnesium intake, indicators of magnesium status, and heart disease. Doctors can evaluate magnesium status when above-mentioned medical problems occur, and determine the need for magnesium supplementation.

Magnesium and osteoporosis
Bone health is supported by many factors, most notably calcium and vitamin D. However, some evidence suggests that magnesium deficiency may be an additional risk factor for postmenopausal osteoporosis [4]. This may be due to the fact that magnesium deficiency alters calcium metabolism and the hormones that regulate calcium (20). Several human studies have suggested that magnesium supplementation may improve bone mineral density [4]. In a study of older adults, a greater magnesium intake maintained bone mineral density to a greater degree than a lower magnesium intake [56]. Diets that provide recommended levels of magnesium are beneficial for bone health, but further investigation on the role of magnesium in bone metabolism and osteoporosis is needed.

What is the health risk of too much magnesium?

Dietary magnesium does not pose a health risk, however pharmacologic doses of magnesium in supplements can promote adverse effects such as diarrhea and abdominal cramping. Risk of magnesium toxicity increases with kidney failure, when the kidney loses the ability to remove excess magnesium. Very large doses of magnesium-containing laxatives and antacids also have been associated with magnesium toxicity [25]. For example, a case of hypermagnesemia after unsupervised intake of aluminum magnesia oral suspension occurred after a 16 year old girl decided to take the antacid every two hours rather than four times per day, as prescribed. Three days later, she became unresponsive and demonstrated loss of deep tendon reflex [57]. Doctors were unable to determine her exact magnesium intake, but the young lady presented with blood levels of magnesium five times higher than normal [25]. Therefore, it is important for medical professionals to be aware of the use of any magnesium-containing laxatives or antacids. Signs of excess magnesium can be similar to magnesium deficiency and include changes in mental status, nausea, diarrhea, appetite loss, muscle weakness, difficulty breathing, extremely low blood pressure, and irregular heartbeat [5,57-60].

References

Table 5 lists the ULs for supplemental magnesium for healthy infants, children, and adults in milligrams (mg) [4]. Physicians may prescribe magnesium in higher doses for specific medical problems. There is no UL for dietary intake of magnesium; only for magnesium supplements.

Table 5: Tolerable Upper Intake Levels for supplemental magnesium for children and adults [4]

Selecting a healthful diet

The 2000 Dietary Guidelines for Americans states, "Different foods contain different nutrients and other healthful substances. No single food can supply all the nutrients in the amounts you need" [61]. If you want more information about building a healthful diet, refer to the Dietary Guidelines for Americans [61] (http://www.usda.gov/cnpp/DietGd.pdf) and the US Department of Agriculture's Food Guide Pyramid [62] (http://www.nal.usda.gov/fnic/Fpyr/pyramid.html).

back to: Alternative Medicine Home ~ Alternative Medicine Treatments

Source: Office of Dietary Supplements - National Institutes of Health

back to: Alternative Medicine Home ~ Alternative Medicine Treatments

References

1. Rude RK. Magnesium deficiency: A cause of heterogeneous disease in humans. J Bone Miner Res 1998;13:749-58. [PubMed abstract]
2. Wester PO. Magnesium. Am J Clin Nutr 1987;45:1305-12. [PubMed abstract]
3. Saris NE, Mervaala E, Karppanen H, Khawaja JA, Lewenstam A. Magnesium: an update on physiological, clinical, and analytical aspects. Clinica Chimica Acta 2000;294:1-26.
4. Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes: Calcium, Phosphorus, Magnesium, Vitamin D and Fluoride. National Academy Press. Washington, DC, 1999.
5. U.S. Department of Agriculture, Agricultural Research Service. 2003. USDA National Nutrient Database for Standard Reference, Release 16. Nutrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/foodcomp.
6. Ford ES and Mokdad AH. Dietary magnesium intake in a national sample of U.S. adults. J Nutr. 2003;133:2879-82.
7. Vormann J. Magnesium: nutrition and metabolism. Molecular Aspects of Medicine 2003:24:27-37.
8. Feillet-Coudray C, Coudray C, Tressol JC, Pepin D, Mazur A, Abrams SA. Exchangeable magnesium pool masses in healthy women: effects of magnesium supplementation. Am J Clin Nutr 2002;75:72-8.
9. Ladefoged K, Hessov I, Jarnum S. Nutrition in short-bowel syndrome. Scand J Gastroenterol Suppl 1996;216:122-31. [PubMed abstract]
10. Rude KR. Magnesium metabolism and deficiency. Endocrinol Metab Clin North Am 1993;22:377-95.
11. Kelepouris E and Agus ZS. Hypomagnesemia: Renal magnesium handling. Semin Nephrol 1998;18:58-73. [PubMed abstract]
12. Ramsay LE, Yeo WW, Jackson PR. Metabolic effects of diuretics. Cardiology 1994;84 Suppl 2:48-56. [PubMed abstract]
13. Kobrin SM and Goldfarb S. Magnesium Deficiency. Semin Nephrol 1990;10:525-35. [PubMed abstract]
14. Lajer H and Daugaard G. Cisplatin and hypomagnesemia. Ca Treat Rev 1999;25:47-58. [PubMed abstract]
15. Tosiello L. Hypomagnesemia and diabetes mellitus. A review of clinical implications. Arch Intern Med 1996;156:1143-8. [PubMed abstract]
16. Paolisso G, Scheen A, D'Onofrio F, Lefebvre P. Magnesium and glucose homeostasis. Diabetologia 1990;33:511-4. [PubMed abstract]
17. Elisaf M, Bairaktari E, Kalaitzidis R, Siamopoulos K. Hypomagnesemia in alcoholic patients. Alcohol Clin Exp Res 1998;22:244-6. [PubMed abstract]
18. Abbott L, Nadler J, Rude RK. Magnesium deficiency in alcoholism: Possible contribution to osteoporosis and cardiovascular disease in alcoholics. Alcohol Clin Exp Res 1994;18:1076-82. [PubMed abstract]
19. Shils ME. Magnesium. In Modern Nutrition in Health and Disease, 9th Edition. (edited by Shils, ME, Olson, JA, Shike, M, and Ross, AC.) New York: Lippincott Williams and Wilkins, 1999, p. 169-92.
20. Elisaf M, Milionis H, Siamopoulos K. Hypomagnesemic hypokalemia and hypocalcemia: Clinical and laboratory characteristics. Mineral Electrolyte Metab 1997;23:105-12. [PubMed abstract]
21. American Diabetes Association. Nutrition recommendations and principles for people with diabetes mellitus. Diabetes Care 1999;22:542-5. [PubMed abstract]
22. Rude RK and Olerich M. Magnesium deficiency: Possible role in osteoporosis associated with gluten-sensitive enteropathy. Osteoporos Int 1996;6:453-61. [PubMed abstract]
23. Bialostosky K, Wright JD, Kennedy-Stephenson J, McDowell M, Johnson CL. Dietary intake of macronutrients, micronutrients and other dietary constituents: United States 1988-94. Vital Heath Stat. 11(245) ed: National Center for Health Statistics, 2002:168.
24. Takahashi M, Degenkolb J, Hillen W. Determination of the equilibrium association constant between Tet repressor and tetracycline at limiting Mg2+ concentrations: a generally applicable method for effector-dependent high-affinity complexes. Anal Biochem 1991;199:197-202.
25. Xing JH and Soffer EE. Adverse effects of laxatives. Dis Colon Rectum 2001;44:1201-9.
26. Qureshi T and Melonakos TK. Acute hypermagnesemia after laxative use. Ann Emerg Med 1996;28:552-5. [PubMed abstract]
27. DePalma J. Magnesium Replacement Therapy. Am Fam Phys 1990;42:173-6.
28. Klasco RK (Ed): USP DI® Drug Information for the Healthcare Professional. Thomson MICROMEDEX, Greenwood Village, Colorado 2003.
29. Fine KD, Santa Ana CA, Porter JL, Fordtran JS. Intestinal absorption of magnesium from food and supplements. J Clin Invest 1991;88:296-402.
30. Firoz M and Graber M. Bioavailaility of US commercial magnesium preparation. Magnes Res 2001;14:257-62.
31. Appel LJ. Nonpharmacologic therapies that reduce blood pressure: A fresh perspective. Clin Cardiol 1999;22:1111-5. [PubMed abstract]
32. Simopoulos AP. The nutritional aspects of hypertension. Compr Ther 1999;25:95-100. [PubMed abstract]
33. Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, Bray GA, Vogt TM, Cutler JA, Windhauser MM, Lin PH, Karanja N. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med 1997;336:1117-24. [PubMed abstract]
34. Sacks FM, Obarzanek E, Windhauser MM, Svetkey LP, Vommer WM, McCullough M, Karanja N, Lin PH, Steele P, Praschen MA, Evans M, Appel LJ, Bray GA, Vogt T, Moore MD for the DASH investigators. Rationale and design of the Dietary Approaches to Stop Hypertension trial (DASH). A multicenter controlled-feeding study of dietary patterns to lower blood pressure. Ann Epidemiol 1995;5:108-18. [PubMed abstract]
35. Sacks FM, Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Bray GA, Vogt TM, Cutler JA, Windhauser MM, Lin PH, Karanja N. A dietary approach to prevent hypertension: A review of the Dietary Approaches to Stop Hypertension (DASH) Study. Clin Cardiol 1999;22:6-10. [PubMed abstract]
36. Svetkey LP, Simons-Morton D, Vollmer WM, Appel LJ, Conlin PR, Ryan DH, Ard J, Kennedy BM. Effects of dietary patterns on blood pressure: Subgroup analysis of the Dietary Approaches to Stop Hypertension (DASH) randomized clinical trial. Arch Intern Med 1999;159:285-93. [PubMed abstract]
37. Ascherio A, Rimm EB, Giovannucci EL, Colditz GA, Rosner B, Willett WC, Sacks FM, Stampfer MJ. A prospective study of nutritional factors and hypertension among US men. Circulation 1992;86:1475-84. [PubMed abstract]
38. Peacock JM, Folsom AR, Arnett DK, Eckfeldt JH, Szklo M. Relationship of serum and dietary magnesium to incident hypertension: the Atherosclerosis Risk in Communities (ARIC) Study. Annals of Epidemiology 1999;9:159-65.
39. National Heart, Lung, and Blood Institute. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1997;157:2413-46. [PubMed abstract]
40. Schwartz GL and Sheps SG. A review of the sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Curr Opin Cardiol 1999;14:161-8. [PubMed abstract]
41. Kaplan NM. Treatment of hypertension: Insights from the JNC-VI report. Am Fam Physician 1998;58:1323-30. [PubMed abstract]
42. Paolisso G, Sgambato S, Gambardella A, Pizza G, Tesauro P, Varricchio H, D'Onofrio F. Daily magnesium supplements improve glucose handling in elderly subjects. Am J Clin Nutr 1992;55:1161-7. [PubMed abstract]
43. Lopez-Ridaura R, Willett WC, Rimm EB, Liu S, Stampfer MJ, Manson JE, Hu FB. Magnesium intake and risk of type 2 diabetes in men and women. Diabetes Care 2004;27:134-40.
44. Meyer KA, Kishi LH, Jacobs DR Jr., Slavin J, Sellers TA, Folsom AR. Carbohydrates, dietary fiber, and incident type 2 diabetes in older women. Am J Clin Nutr 1999;71:921-30.
45. Song V, Manson JE, Buring JE, Liu S. Dietary magnesium intake in relation to plasma insulin levels and risk of type 2 diabetes in women. Diabetes Care 2003;27:59-65.
46. Kao WHL, Folsom AR, Nieto FJ, MO JP, Watson RL, Brancati FL. Serum and dietary magnesium and the risk for type 2 diabetes: The Atherosclerosis Risk in Communities Study. Arch Intern Med 1999;159:2151-59.
47. Rodriguez-Moran M and Guerrero-Romero F. Oral magnesium supplementation improves insulin sensitivity and metabolic control in type 2 diabetic subjects. Diabetes Care 2003;26:1147-52.
48. De Lourdes Lima, M, Cruz T, Pousada JC, Rodrigues LE, Barbosa K, Canguco V. The effect of magnesium supplementation in increasing doses on the control of type 2 diabetes. Diabetes Care 1998;21:682-86.
49. Altura BM and Altura BT. Magnesium and cardiovascular biology: An important link between cardiovascular risk factors and atherogenesis. Cell Mol Biol Res 1995;41:347-59. [PubMed abstract]
50. Ford ES. Serum magnesium and ischaemic heart disease: Findings from a national sample of US adults. Intl J of Epidem 1999;28:645-51. [PubMed abstract]
51. Liao F, Folsom A, Brancati F. Is low magnesium concentration a risk factor for coronary heart disease? The Atherosclerosis Risk in Communities (ARIC) Study. Am Heart J 1998;136:480-90. [PubMed abstract]
52. Ascherio A, Rimm EB, Hernan MA, Giovannucci EL, Kawachi I, Stampfer MJ, Willett WC. Intake of potassium, magnesium, calcium, and fiber and risk of stroke among US men. Circulation 1998;98:1198-204. [PubMed abstract]
53. Shechter M, Bairey Merz CN, Stuehlinger HG, Slany J, Pachinger O, Rabinowitz B. Effects of oral magnesium therapy on exercise tolerance, exercise-induced chest pain, and quality of life in patients with coronary artery disease. Am J Cardiol 2003;91:517-21.
54. Shechter M, Sharir M, Labrador MJ, Forrester J, Silver B, Bairey Merz CN. Oral magnesium therapy improves endothelial function in patients with coronary artery disease. Circulation 2000;102:2353-58.
55. Shechter M, Merz CN, Paul-Labrador M, Meisel SR, Rude RK, Molloy MD, Dwyer JH, Shah PK, Kaul S. Oral magnesium supplementation inhibits platelet-dependent thrombosis in patients with coronary artery disease. American Journal of Cardiology 1999;84:152-6.
56. Tucker KL, Hannan MT, Chen H, Cupples LA, Wilson PW, Kiel DP. Potassium, magnesium, and fruit and vegetable intakes are associated with greater bone mineral density in elderly men and women. Am J Clin Nutr 1999;69(4):727-36.
57. Jaing T-H, Hung I-H, Chung H-T, Lai C-H, Liu W-M, Chang K-W. Acute hypermagnesemia: a rare complication of antacid administration after bone marrow transplantation. Clinica Chimica Acta 2002;326:201-3.
58. Whang R. Clinical disorders of magnesium metabolism. Compr Ther 1997;23:168-73. [PubMed abstract]
59. Ho J, Moyer TP, Phillips S. Chronic diarrhea: The role of magnesium. Mayo Clin Proc 1995;70:1091-2. [PubMed abstract]
60. Nordt S, Williams SR, Turchen S, Manoguerra A, Smith D, Clark R. Hypermagnesemia following an acute ingestion of Epsom salt in a patient with normal renal function. J Toxicol Clin Toxicol 1996;34:735-9. [PubMed abstract]
61. Dietary Guidelines Advisory Committee, Agricultural Research Service, United States Department of Agriculture (USDA). HG Bulletin No. 232, 2000. http://www.usda.gov/cnpp/DietGd.pdf.
62. Center for Nutrition Policy and Promotion, United Stated Department of Agriculture. Food Guide Pyramid, 1992 (slightly revised 1996). http://www.nal.usda.gov/fnic/Fpyr/pyramid.html.

About ODS an the NIH Clinical Center

Disclaimer
Reasonable care has been taken in preparing this document and the information provided herein is believed to be accurate. However, this information is not intended to constitute an "authoritative statement" under Food and Drug Administration rules and regulations.

The mission of the Office of Dietary Supplements (ODS) is to strengthen knowledge and understanding of dietary supplements by evaluating scientific information, stimulating and supporting research, disseminating research results, and educating the public to foster an enhanced quality of life and health for the U.S. population.

The NIH Clinical Center is the clinical research hospital for NIH. Through clinical research, physicians and scientist translate laboratory discoveries into better treatments, therapies and interventions to improve the nation's health.

General Safety Advisory

Health professionals and consumers need credible information to make thoughtful decisions about eating a healthful diet and using vitamin and mineral supplements. To help guide those decisions, registered dietitians at the NIH Clinical Center developed a series of Fact Sheets in conjunction with ODS. These Fact Sheets provide responsible information about the role of vitamins and minerals in health and disease. Each Fact Sheet in this series received extensive review by recognized experts from the academic and research communities.

The information is not intended to be a substitute for professional medical advice. It is important to seek the advice of a physician about any medical condition or symptom. It is also important to seek the advice of a physician, registered dietitian, pharmacist, or other qualified health professional about the appropriateness of taking dietary supplements and their potential interactions with medications.

back to: Alternative Medicine Home ~ Alternative Medicine Treatments

Question:

Why is there no connection between the behaviour of the narcissist and his emotions?

Answer:

A better way of putting it would be that there is a weak correlation between the narcissist's behaviour and his professed or proclaimed emotions. The reason is that the latter are merely professed or proclaimed - but not felt. The narcissist fakes feelings and their outer expression in order to impress others, to gain their sympathy or to motivate them to act in a manner benefiting the narcissist and promoting his interests.

In this - as in many other simulated behaviour patterns - the narcissist seeks to manipulate his human environment. Inside, he is barren, devoid of any inkling of true feeling, even mocking. He looks down upon those who succumb to the weakness of experiencing emotions and holds them in contempt. He berates and debases them.

This is the heartless mechanism of "simulated affect". This mechanism lies at the core of the narcissist's inability to empathise with his fellow human beings.

The narcissist constantly lies to himself and to others. He defensively self-deludes, distorts facts and circumstances, provides comfortable (consonant) interpretations - all so as to preserve his delusions of grandeur and feelings of (unmerited) self-importance. This is the mechanism of the "sliding of meanings". This mechanism is part of the much larger set of Emotional Involvement Prevention Measures (EIPMs).

The EIPMs are intended to prevent the narcissist from getting emotionally involved or committed. This way the narcissist insures himself against getting hurt and abandoned, or so he erroneously believes. In actuality, these mechanisms are self-defeating and lead directly to the results they were intended to forestall. They mostly operate through versions of emotional denial. The narcissist is estranged from his own emotions as a means of self-defence.

Another characteristic of the narcissistic personality is the use that it makes of "emotional delegation". The narcissist - despite appearances - is human and is possessed of emotions and of emotional content. But, in an effort to defend himself against a repetition of past hurts, he "delegates" his emotions to a fictitious self, the False Self.

It is the False Self that interacts with the world. It is the False Self that suffers and enjoys, gets attached and detached, joins and separates, develops likes and dislikes, preferences and prejudices, loves and hates. Whatever happens to the narcissist, his experiences, the setbacks that he (inevitably) suffers, the humiliations, the adoration, the fears and the hopes - all these happen to one self removed, to the False Self.

The narcissist is shielded by this construction. He lives in a padded cell of his own creation, an eternal observer, unharmed, embryo-like in the womb of his True Self. No wonder that this duality, so entrenched, so fundamental to the narcissistic personality - is also so evident, so discernible. This delegation of emotions is what unsettles those who interact with the narcissist: the feeling that his True Self is absent and that all the emoting is done by a false emanation.

The narcissist himself experiences this dichotomy, this break between his False Self which is his interface with the true world - and his True Self which is forever dormant in a no-man's land. The narcissist lives in this warped reality, divorced from his own emotions, constantly feeling that he is an actor in a film featuring his life.

A more detailed description of this emotional break can be found in "Warped Reality and Retroactive Emotional Content".

next: Narcissism By Proxy

Question:

The symptoms that you describe are common to so many people that I know... Does this mean that they are all narcissists?

Answer:

The Diagnostic and Statistical Manual (DSM) is linear, descriptive (phenomenological), and bureaucratic. It is "medical", "mechanic-dynamic", and "physical" and, thus, reminiscent of the old taxonomies in Botany and Zoology. It glosses over the patient's idiosyncratic life circumstances, biological and psychological processes, and offers no overarching conceptual and exegetic framework. Moreover, the DSM is heavily influenced by cultural fashions, prevailing social lore and ethos, and by the legal and business environment.

We are all narcissists at an early stage of our lives. As infants, we feel that we are the centre of the universe, omnipotent and omniscient. Our parents, those mythical figures, immortal and awesomely powerful, are there only to protect and serve us. Both self and others are viewed immaturely, as idealisations.

Inevitably, the inexorable processes and conflicts of life grind these ideals into the fine dust of the real. Disappointments follow disillusionment. When these are gradual and tolerable, they are adaptative. If abrupt, capricious, arbitrary, and intense, the injuries sustained by the tender, budding self-esteem, are irreversible.

Moreover, the empathic support of the caretakers (the Primary Objects, the parents) is crucial. In its absence, self-esteem in adulthood tends to fluctuate, to alternate between over-valuation (idealisation) and devaluation of both self and others.

Narcissistic adults are the result of bitter disappointments, of radical disillusionment with parents, role models, or peers. Healthy adults accept their limitations (the boundaries of their selves). They accept disappointments, setbacks, failures, criticism and disillusionment with grace and tolerance. Their sense of self-worth is constant and positive, minimally affected by outside events, no matter how severe.

The common view is that we go through the stages of a linear development. We are propelled forward by various forces: the Libido (force of life) and the Thanatos (force of death) in Freud's tripartite model, Meaning in Frenkel's work, socially mediated phenomena (in both Adler's thinking and in Behaviourism), our cultural context (in Horney's opera), interpersonal relations (Sullivan) and neurobiological and neurochemical processes, to mention but a few schools of developmental psychology.

In an effort to gain respectability, many scholars attempted to propose a "physics of the mind". But these thought systems differ on many issues. Some say that personal development ends in childhood, others - during adolescence. Yet others say that development is a process which continues throughout the life of the individual.

Common to all these schools of thought are the mechanics and dynamics of the process of personal growth. Forces - inner or external - facilitate the development of the individual. When an obstacle to development is encountered, development is stunted or arrested - but not for long. A distorted pattern of development, a bypass appears.

Psychopathology is the outcome of perturbed growth. Humans can be compared to trees. When a tree encounters a physical obstacle to its expansion, its branches or roots curl around it. Deformed and ugly, they still reach their destination, however late and partially.

Psychopathologies are, therefore, adaptative mechanisms. They allow the individual to continue to grow around obstacles. The nascent personality twists and turns, deforms itself, is transformed - until it reaches a functional equilibrium, which is not too ego-dystonic.

Having reached that point, it settles down and continues its more or less linear pattern of growth. The forces of life (as expressed in the development of the personality) are stronger than any hindrance. The roots of trees crack mighty rocks, microbes live in the most poisonous surroundings.

Similarly, humans form those personality structures which are optimally suited to their needs and outside constraints. Such personality configurations may be abnormal - but their mere existence proves that they have triumphed in the delicate task of successful adaptation.

Only death puts a stop to personal growth and development. Life's events, crises, joys and sadness, disappointments and surprises, setbacks and successes - all contribute to the weaving of the delicate fabric called "personality".

When an individual (at any age) encounters an obstacle to the orderly progression from one stage of development to another - he retreats at first to his early childhood's narcissistic phase rather than circumvent or "go around" the hindrance.

The process is three-phased:

(1) The person encounters an obstacle

(2) The person regresses to the infantile narcissistic phase

(3) Thus recuperated, the person confronts the obstacle again.

While in step (2), the person displays childish, immature behaviours. He feels that he is omnipotent and misjudges his powers and the might of the opposition. He underestimates challenges facing him and pretends to be "Mr. Know-All". His sensitivity to the needs and emotions of others and his ability to empathise with them deteriorates sharply. He becomes intolerably haughty with sadistic and paranoid tendencies.

Above all, he then demands unconditional admiration, even when he does not deserve it. He is preoccupied with fantastic, magical, thinking and daydreams his life away. He tends to exploit others, to envy them, to be edgy and explode with unexplained rage.

People whose psychological development is obstructed by a formidable obstacle - mostly revert to excessive and compulsive behaviour patterns. To put it succinctly: whenever we experience a major life crisis (which hinders our personal growth and threatens it) - we suffer from a mild and transient form of the Narcissistic Personality Disorder.

This fantasy world, full of falsity and hurt feelings, serves as a springboard from which the rejuvenated individual resumes his progress towards the next stage of personal growth. This time around, faced with the same obstacle, he feels sufficiently potent to ignore it or to attack it.

In most cases, the success of this second onslaught is guaranteed by the delusional assessment that the obstacle's fortitude and magnitude are diminished. This, indeed, is the main function of this reactive, episodic, and transient narcissism: to encourage magical thinking, to wish the problem away or to enchant it or to tackle and overcome it from a position of omnipotence.

A structural abnormality of personality arises only when recurrent attacks fail constantly and consistently to eliminate the obstacle, or to overcome the hindrance. The contrast between the fantastic world (temporarily) occupied by the individual and the real world in which he keeps being frustrated - is too acute to countenance for long without a resulting deformity.

This dissonance - the gap between grandiose fantasy and frustrating reality - gives rise to the unconscious "decision" to go on living in the world of fantasy, grandiosity and entitlement. It is better to feel special than to feel inadequate. It is better to be omnipotent than psychologically impotent. To (ab)use others is preferable to being (ab)used by them. In short: it is better to remain a pathological narcissist than to face harsh, unyielding reality.

Not all personality disorders are fundamentally narcissistic. Yet, I think that the default, when growth is stunted by the existence of a persistent obstacle, is remission to the the narcissistic phase of early personal development. I further believe that this is the ONLY default available to the individual: whenever he comes across an obstacle, he regresses to the narcissistic phase. How can this be reconciled with the diversity of mental illnesses?

"Narcissism" is the substitution of a False Self for the True Self. This, arguably, is the predominant feature of narcissism: the True Self is repressed, relegated to irrelevance and obscurity, left to degenerate and decay. In its stead, a psychological structure is formed and projected unto the outside world - the False Self.

The narcissist's False Self is reflected at him by other people. This "proves" to the narcissist that the False Self indeed exists independently, that it is not entirely a figment of the narcissist's imagination and, therefore, that it is a legitimate successor to the True Self. It is this characteristic which is common to all psychopathologies: the emergence of false psychic structures which usurp the powers and capacities of the previous, legitimate and authentic ones.

Horrified by the absence of a clearly bounded, cohesive, coherent, reliable, and self-regulating self - the mentally abnormal person resorts to one of the following solutions, all of which involve reliance upon fake or invented personality constructs:

1. The Narcissistic Solution - The True Self is replaced by a False Self. The Schizotypal Personality Disorder also largely belongs here because of its emphasis on fantastic and magical thinking. The Borderline Personality Disorder (BPD) is a case of a failed narcissistic solution. In BPD, the patient is aware that the solution that she opted for is "not working". This is the source of her separation anxiety (fear of abandonment). This generates her identity disturbance, her affective and emotional lability, suicidal ideation and suicidal action, chronic feelings of emptiness, rage attacks, and transient (stress related) paranoid ideation.
2. The Appropriation Solution - This is the appropriation, or the confiscation of someone else's self in order to fill the vacuum left by the absence of a functioning Ego. While some Ego functions are available internally - others are adopted by the "appropriating personality". The Histrionic Personality Disorder is an example of this solution. Mothers who "sacrifice" their lives for their children, people who live vicariously, through others - all belong to this category. So do people who dramatise their lives and their behaviour, in order to attract attention. The "appropriators" misjudge the intimacy of their relationships and the degree of commitment involved, they are easily suggestible and their whole personality seems to shift and fluctuate with input from the outside. Because they have no Self of their own (even less so than "classical" narcissists) - the "appropriators" tend to over-rate and over-emphasise their bodies. Perhaps the most striking example of this type of solution is the Dependent Personality Disorder.

1. The Schizoid Solution - These patients are mental zombies, trapped forever in the no-man's land between stunted growth and the narcissistic default. They are not narcissists because they lack a False Self - nor are they fully developed adults, because their True Self is immature and dysfunctional. They prefer to avoid contact with others (they lack empathy, as does the narcissist) in order not to upset their delicate tightrope act. Withdrawing from the world is an adaptive solution because it does not expose the patient's inadequate personality structures (especially his self) to onerous - and failure bound - tests. The Schizotypal Personality Disorder is a mixture of the narcissistic and the schizoid solutions. The Avoidant Personality Disorder is a close kin.
2. The Aggressive Destructive Solution - These people suffer from hypochondriasis, depression, suicidal ideation, dysphoria, anhedonia, compulsions and obsessions and other expressions of internalised and transformed aggression directed at a self which is perceived to be inadequate, guilty, disappointing and worthy of nothing but elimination. Many of the narcissistic elements are present in an exaggerated form. Lack of empathy becomes reckless disregard for others, irritability, deceitfulness and criminal violence. Undulating self-esteem is transformed into impulsiveness and failure to plan ahead. The Antisocial Personality Disorder is a prime example of this solution, whose essence is: the total control of a False Self, without the mitigating presence of a shred of True Self.

Perhaps this common feature - the replacement of the original structures of the personality by new, invented, mostly false ones - is what causes one to see narcissists everywhere. This common denominator is most accentuated in the Narcissistic Personality Disorder.

The interaction, really, the battle, between the struggling original remnants of the personality and the malignant and omnivorous new structures - can be discerned in all forms of psychic abnormality. The question is: if many phenomena have one thing in common - should they be considered one and the same, or, at least, caused by the same?

I say that the answer in the case of personality disorders should be in the affirmative. I think that all the known personality disorders are forms of malignant self-love. In each personality disorder, different attributes are differently emphasised, different weights attach to different behaviour patterns. But these, in my view, are all matters of quantity, not of quality. The myriad deformations of the reactive patterns collectively known as "personality" all belong to the same family.

next: The Narcissist's Inappropriate Affect

• Watch the video on The Narcissist's Life, a Prolonged Nightmare

Question:

How does a narcissist experience his own life?

Answer:

As a prolonged, incomprehensible, unpredictable, frequently terrifying and deeply saddening nightmare. This is a result of the functional dichotomy - fostered by the narcissist himself - between his False Self and his True Self. The latter - the fossilised ashes of the original, immature, personality - is the one that does the experiencing.

The False Self is nothing but a concoction, a figment of the narcissist's disorder, a reflection in the narcissist's hall of mirrors. It is incapable of feeling, or experiencing. Yet, it is fully the master of the psychodynamic processes which rage within the narcissist's psyche.

This inner battle is so fierce that the True Self experiences it as a diffuse, though imminent and eminently ominous, threat. Anxiety ensues and the narcissist finds himself constantly ready for the next blow. He does things and he knows not why or wherefrom. He says things, acts and behaves in ways, which, he knows, endanger him and put him in line for punishment.

The narcissist hurts people around him, or breaks the law, or violates accepted morality. He knows that he is in the wrong and feels ill at ease on the rare moments that he does feel. He wants to stop but knows not how. Gradually, he is estranged from himself, possessed by some kind of demon, a puppet on invisible, mental strings. He resents this feeling, he wants to rebel, he is repelled by this part in him with which he is not acquainted. In his efforts to exorcise this devil from his soul, he dissociates.

An eerie sensation sets in and pervades the psyche of the narcissist. At times of crisis, of danger, of depression, of failure, and of narcissistic injury - the narcissist feels that he is watching himself from the outside. This is not an out-of-body experience. The narcissist does not really "exit" his body. It is just that he assumes, involuntarily, the position of a spectator, a polite observer mildly interested in the whereabouts of one, Mr. Narcissist.

It is akin to watching a movie, the illusion is not complete, neither is it precise. This detachment continues for as long as the narcissist's ego-dystonic behaviour persists, for as long as the crisis goes on, for as long as the narcissist cannot face who he is, what he is doing and the consequences of his actions.

Since this is the case most of the time, the narcissist gets used to seeing himself in the role of the protagonist (usually the hero) of a motion picture or of a novel. It also sits well with his grandiosity and fantasies. Sometimes, he talks about himself in the third person singular. Sometimes he calls his "other", narcissistic, self by a different name.

He describes his life, its events, ups and downs, pains, elation and disappointments in the most remote, "professional" and coldly analytical voice, as though describing (though with a modicum of involvement) the life of some exotic insect (echoes of Kafka's "Metamorphosis").

The metaphor of "life as a movie", gaining control by "writing a scenario" or by "inventing a narrative" is, therefore, not a modern invention. Cavemen narcissists have, probably, done the same. But this is only the external, superficial, facet of the disorder.

The crux of the problem is that the narcissist really FEELS this way. He actually experiences his life as belonging to someone else, his body as dead weight (or as an instrument in the service of some entity), his deeds as a-moral and not immoral (he cannot be judged for something he didn't do now, can he?).

As time passes, the narcissist accumulates a mountain of mishaps, conflicts unresolved, pains well hidden, abrupt separations and bitter disappointments. He is subjected to a constant barrage of social criticism and condemnation. He is ashamed and fearful. He knows that something is wrong but there is no correlation between his cognition and his emotions.

He prefers to run away and hide, as he did when he was a child. Only this time he hides behind another self, a false one. People reflect to him this mask of his creation, until even he believes its very existence and acknowledges its dominance, until he forgets the truth and knows no better. The narcissist is only dimly aware of the decisive battle, which rages inside him. He feels threatened, very sad, suicidal - but there seems to be no outside cause of all this and it makes it even more mysteriously menacing.

This dissonance, these negative emotions, these nagging anxieties, transform the narcissist's "motion picture" solution into a permanent one. It becomes a feature of the narcissist's life. Whenever confronted by an emotional threat or by an existential one - he retreats into this haven, this mode of coping.

He relegates responsibility, submissively assuming a passive role. He who is not responsible cannot be punished - runs the subtext of this capitulation. The narcissist is thus conditioned to annihilate himself - both in order to avoid (emotional) pain and to bask in the glow of his impossibly grandiose fasntasies.

This he does with fanatic zeal and with efficacy. Prospectively, he assigns his very life (decisions to be made, judgements to be passed, agreements to be reached) to the False Self. Retroactively, he re-interprets his past life in a manner consistent with the current needs of the False Self.

It is no wonder that there is no connection between what the narcissist did feel in a given period in his life, or in relation to a specific event - and the way he sees or remembers these later on. He may describe certain occurrences or phases in his life as "tedious, painful, sad, burdening" - even though he experienced them entirely differently at the time.

The same retroactive colouring occurs with regards to people. The narcissist completely distorts the way he regarded certain people and felt about them. This re-writing of his personal history is aimed to directly and fully accommodate the requirements of his False Self.

In sum, the narcissist does not occupy his own soul, nor does he inhabit his own body. He is the servant of an apparition, of a reflection, of an Ego function. To please and appease his Master, the narcissist sacrifices to it his very life. From that moment onwards, the narcissist lives vicariously, through the good offices of the False Self.

Throughout, the narcissist feels detached, alienated and estranged from his (False) Self. He constantly harbours the sensation that he is watching a movie with a plot over which he has little control. It is with a certain interest - even fascination - that he does the watching. Still, it is mere, passive observation.

Thus, not only does the narcissist relinquish control of his future life (the movie) - he gradually loses ground to the False Self in the battle to preserve the integrity and genuineness of his past experiences. Eroded by these two processes, the narcissist gradually disappears and is replaced by his disorder to the fullest extent

next: Self-Defeating and Self-Destructive Behaviours

Thoughtful quotes about opportunity and opportunities in life.

Words of Wisdom

"A wise man will make more opportunities than he finds." (Frances Bacon, Essays)

"God makes opportunities but he expects us to hunt for them." (Author Unknown)

"The greatest opportunities occur during depressed and discouraging periods, but it is very difficult to recognize them at such times." (Author Unknown)

"Problems are only opportunities in work clothes." (Henry J. Kaiser)

"Every calamity is a spur and valuable hint." (Ralph Waldo Emerson)

"There is the greatest practical benefit in making a few failures early in life." (Thomas Henry Huxley)

"The secret of success in life is for a man to be ready for his opportunity when it comes." (Benjamin Disraeli)

"People are always blaming their circumstances for what they are...The people who get on in this world are the people who get up and look for the circumstances they want, and, if they can't find them, make them." (George Bernard Shaw)

"We are continually faced with great opportunities brilliantly disguised as insoluble problems." (Author unknown)

"Failure is only the opportunity to begin again, more intelligently." (Henry Ford)

next:Parenting/Motherhood

Self-Therapy For People Who ENJOY Learning About Themselves

As I write this, our country is rightly embarrassed and understandably shocked after learning about prisoner abuse and other atrocities committed by us, and against us, during war.

As a therapist, I know that abuse doesn't occur only in war. I hear nearly every day about abuse committed by parents, partners, and clergy.

How can such horrors happen? What can we do to stop it?

HUMAN NATURE

We all have a natural ability to momentarily enjoy hurting others. Such sadistic behavior shows itself strongly in pre-adolescent children. At these ages, boys feel glee at physically mistreating playmates and animals, and girls derive pleasure from gossiping about and demeaning their peers.

After proper, non-violent handling of this misbehavior by the adults, most of us stop doing such things. But the ability to feel very short-lived glee while hurting others is still in our genes.

Adults who were brutally disciplined as children or who live in violent or deprived situations into their adult years can maintain and even strengthen these impulses. These are the people who may choose to abuse.

DESPERATION

Both the abuser and the abused need to believe they have no other worthwhile choices. Whether they are children, insecure spouses, faithful followers of some "all powerful" religious system, or soldiers who believe they must please their powerful superiors to survive, the abuser and the abused see themselves as desperate. Only desperate people live with abuse.

FAITH WITHOUT DOUBT

Young children have no choice but to believe in their parents' power. Spouses may believe too strongly in their partner, or in the power of love. Those abused by clergy can believe too much in their leaders, or in what the leaders are preaching. Soldiers can believe too much that their country is right no matter what it does.

Faith without doubt is a necessary component of all abuse. It doesn't cause abuse, but it provides fertile ground so abuse can flourish.

ABSOLUTE POWER

"Power corrupts, and absolute power corrupts absolutely."

'Nuff said!

WHAT CAN WE DO TO STOP IT?

ABOUT HUMAN NATURE:
We can't change human nature but we'd better be alert to it. If we treat others as if they shouldn't have power they will want to use their power on us.

ABOUT DESPERATION:
Everyone must have healthy options. The only legitimate use of economic, social, political, religious, and military power is to provide what humans need. Eliminate desperation to eliminate horror.

ABOUT BELIEF WITHOUT DOUBT:
When your government, partner, religious leader, or military superior insists that you believe something without doubt, you are in danger! Protect yourself by maintaining your right to doubt,
even if you choose to believe. And teach everyone you know to do the same. People who insist that you believe them without doubt may be good, misguided people who love you, but they are wrong. Maintain your right to doubt. Never give up your right to think.

ABOUT ABSOLUTE POWER:
Insist that all power must be shared. Cooperate wisely. Share your power but do not relinquish it.

ELIMINATING ABUSE

Most parents, spouses, clergy, and soldiers do not abuse. Most adults do not abuse.

Those who do abuse need their victims to "cooperate" by:
believing they are desperate,
giving up their right to think,
and deciding they are powerless.

Never give abusers the tools they need to hurt you.

Keep your power.

Enjoy Your Changes!

Everything here is designed to help you do just that!

next: Sexual Abuse In Childhood

Self-Therapy For People Who ENJOY Learning About Themselves

On all topics related to childhood sexual abuse, please understand that by using female pronouns I am definitely not saying that all abuse happens to girls. It happens about twice as often to girls, but abuse is abuse and it's horrible in any form. If you are thinking about a boy, please change the pronouns as you read.

DIFFERENT THERAPISTS, DIFFERENT APPROACHES

There are differences of opinion in all areas of mental health. The opinions given here are only mine. There are other competent opinions.

There are also differences among those who have been sexually abused.

Some people were hurt more than others.

Some people "split" more often than others.

Some people have only one flashback in a lifetime while others have daily flashbacks for months.

My opinions, by necessity, aim at the "average."

Considering all factors, all adult victims of childhood sexual abuse need:

• DAILY SELF-CARE
• PSYCHOTHERAPY
• A REGULAR SOURCE OF SUPPORT
• BODY WORK

It would be ideal if everyone did all of these things at once, but it is not necessary. Most people start with therapy, then add the other elements as their healing continues.

These four elements are listed in order of importance, not in usual chronological order.
(Daily self-care IS the most important, but, sadly, it is often the last thing victims feel strong enough to do.)

By daily self-care I mean devoting a half-hour to an hour each day (not more) to nothing but your healing!

This time should be spent in any safe activity which has the purpose of healing from abuse.

It might include reading about healing, relaxing in a warm tub, attending therapy or support groups, whatever...

The regularity of this time for yourself is very important.

What Happens During Self-Care: The little girl inside gets soothed - not just by that day's activities - but also by knowing there will be more for her tomorrow.

The adult gets soothed and impressed by her own competence at self-care, and by the practice she gets at being enough for herself, and by the practice she gets at being aware of her feelings and her thinking simultaneously.

Don't settle for less than a good therapist who feels right to you, who is willing to see you at least weekly in the beginning, and who believes in his or her own competence when it comes to working with sexual abuse.

Beware of any therapist who says that short-term therapy is appropriate! This therapist is putting the insurance company's desire to control costs ahead of your need to heal from the abuse!

(Also see "Therapist's Responsibilities" in the article on "False Memories and Responsibilities.")

The regular source referred to here means in addition to family and friends.

Just like all of the other things listed, this support needs to be very reliable.

If you live in a large enough city you will probably be able to find a support group specifically designed for adult survivors of childhood sexual abuse. Attend a few meetings to see if the group feels supportive and healing to you. If it doesn't, keep looking until you find the right one.

If there are no support groups in your area, here are some other good ways to get support:

• A church or other social group that gives LOTS of support. Other members should know about the abuse, even if it isn't often discussed.
• "E-mail Advice" Services (my own or some other good therapist's). "E-mail Advice" may not be powerful enough to qualify as real therapy - but it can be a major source for support and counseling.
• Internet "Chat Rooms" specifically designated as sexual abuse support groups and moderated by a therapist.
• Talking REGULARLY with one or two others who have been abused sexually and are healing in ways that are consistent with the ways you have chosen.
• A support group that is not specifically focused on healing from sexual abuse (as long as members know about the abuse and support your other healing activities).

BODY WORK

The purpose of all body work is: To teach you how strong you are physically, as an adult.

Some people take karate classes, others get regular therapeutic massages, others work out on their own.

Almost any intense use of your body, if it is regularly scheduled, will work.

For reasons too complicated to go into here, you should know that any physical activity that is "rhythmic" (like hitting a punching bag repeatedly, or jogging) will be far less helpful for you than non-rhythmic activities.

HEALING FROM SEXUAL ABUSE IS NOT AN "OPTION."

You will either do it by my plan, or by someone else's plan, or in your own planned or unplanned way.

But you will be healing all your life.

It's only natural. It cannot be avoided.

Enjoy Your Changes!

Everything here is designed to help you do just that!

next: How Does Abuse Happen?