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Dr. Arun Phophalia
Dr. Arun Phophalia, Doctor (MD)
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Experience:  MBBS, MS (General Surgery), Fellowship in Sports Medicine
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I have been taking iron 50mg for over 8 months but still

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I have been taking iron 50mg for over 8 months but still show mild Anemia. The only drugs I have been taking are Mucinex consistently and Pseudoephedrine occasionally. I have read that Mucinex can act as a mild blood thinner and anti-coagulant. I have also seen it mentioned that it can irritate the gastric mucosa, and have some effect on hemolysis (destroying RBCs).
I have been feeling more prounounced symptoms of Anemia lately and it seemed to occur after having increased the dose of Mucinex for about 2 weeks. My stool has been dark as long as I have been taking iron and clears up when I stop. How can I tell if there is any internal bleeding if the iron keeps my stool dark?
Is it possible that the Mucinex could have worsened the Anemia or caused some bleeding? I have noticed when I get cuts the blood is thinner than usual.

Greetings Brandon.

I am sorry that your question was unanswered for considerable time.

A persistent mild anemia would warrant further detailed investigations by your doctor in your age group. Mucinex alone is not likely to be responsible for anemia and explain it. As a matter of fact, Mucinex should not be taken for long term because a chronic cough and mucus in chest also need further investigation to ascertain the cause. So your symptoms for which Mucinex is required also need thorough evaluation. The only way to know about the bleeding in stomach (commonly due to ulcers / sores) is by stool test after stopping the iron supplement for 3-4 days. Since your stools clear up after stopping the iron; chance of bleeding is less. A colonoscopy is usually advised as there can be polyps in the intestines (benign growths) which can bleed intermittently and can cause anemia. Ferritin is a blood test which evaluates for the total iron available in the body. Serum ferritin is the most useful test for diagnosing iron-deficiency anemia. Low serum ferritin (less than 12 ng/mL) is highly specific for iron-deficiency anemia. Please read this resource;

The most common causes of anemia are;

1) iron deficiency (with or without blood loss),

2) chronic disease/inflammation

3) chronic kidney disease

4) deficiencies of folate or vitamin B-12,

5) diseases of the bone marrow

6) hypothyroidism, hypersplenism, and hemolytic anemia

So investigations entail;

1) Complete blood count (CBC)

2) Peripheral blood film

3) Vitamin B-12

4) Folate

5) Reticulocyte count

6) LDH

7) Thyroid-stimulating hormone

8) Serum creatinine and estimated glomerular filtration rate

9) Serum ferritin

10) Serum iron

11) Total iron-binding capacity

So these investigations and revaluation need to be done for the exact assessment and long term management.

Please feel free for your follow up questions.

I would be happy to assist you further, if you need any more information.

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Customer: replied 4 years ago.

Thank you for your thorough reply. I have a few follow up questions.

You said that Mucinex alone would likely not cause Anemia. Can it be of a factor to any degree? I know one way it works is by thinning mucus so would that include the gastrointestinal mucus and possibly lead to bleeding?

Would the other potential actions I mentioned above (hemolysis, anti-coagulant, blood thinning) have an effect, even if only small? I have always been overly sensitive to drugs and nearly died 8 months ago from internal bleeding seeming mostly caused by Aspirin but I was also taking larger doses of Mucinex at that time too. I have not taken any Aspirin or NSAIDS since then.

I was steadily improving from that much worse Anemia and suddenly the symptoms became worse very recently when I had increased the Mucinex substantially. It could be a coincidence but that is the only drug besides sudafed that I was using. Is sudafed any risk for bleeding? I can't find any information suggesting that. However I can find information suggesting it for Mucinex, albeit not frequent.

Hello and welcome Brandon,

Mucinex alone is quite unlikely to be responsible for the iron deficiency or anemia or gastrointestinal bleeding. There has to be other concomitant cause. The other adverse effects like hemolysis, anti-coagulation and blood thinning too are not common but cannot be completely ruled out. So a possibility (albeit low) do exist, especially with a observation of cause and effect relationship (increased dose worsening anemia). Sudafed, as you mentioned is not to be the likely explanation of worsening of the anemia. But both of these (Sudafed and Mucinex) should not be taken for long duration.

It is privilege assisting you.
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Customer: replied 4 years ago.

Is there are any way to tell if there is blood in my stool without having to do the test at the doctor? Is there a way to determine this at home since I can't get every movement checked by a doctor? I might have been losing blood in small amounts at times but would never notice because the iron turns it black as if there is massive bleeding.

Hello Brandon,

There are home tests for the blood in stool. The brand names of the test are; EZ-Detect and ColoCARE. The package insert would tell you to stop eating specific foods and medications which can interfere with the tests. You would need to stop the iron supplements for 3 days before you perform the test at home.
Customer: replied 4 years ago.

Having to go off iron for 3 days defeats the whole purpose because then my stool would no longer be turning black from the iron and I would be able to see if there is substantial bleeding if it were still dark.

I am asking if there is a way to check without having to stop the iron. The doctor tested it in just a few minutes in his office. Is the test he used, or something similar, available for home use?

If not are there ways to make a distinction between black stool being caused by blood or by iron? Until I found out I was still Anemic I was only taking 25mg per day and my stool would only be green rather than black. If there were blood could it be green or does the presence of blood turn it only black or some other color?


Unfortunately there are no home tests which can detect blood without stopping the iron. The home tests detect the heme component (which is similar to iron and thus could not differentiate) of hemoglobin which is present in the blood. I feel that it would not defeat the purpose because if the blood is not detected in the stool after stopping iron; you can conclude that black color of the stool is because of iron. Iron and PeptoBismol are the commonest cause of black stool. A substantial bleeding in your case is again not much likely for following reasons;

1) it causes profound anemia very fast.
2) a significant bleeding causes black tarry stool which are foul smelling.
3) stopping of iron would give significant persistent black color in GI bleeding.

In your age group, anemia is uncommon due to the gastrointestinal bleeding except due to polyps which have usually a family history. The other cause of GI bleeding in your age group is peptic ulcer which cause significant symptoms like heartburn, bloating, gas, indigestion, pain after meals, abdominal cramps etc.

The blood in stool would cause black color stool and no other color.

But again, I would not be suspecting a significant bleeding in your case from the GI tract. I would look for other causes of anemia by the investigations.
Customer: replied 4 years ago.

Actually I am at high risk of GI bleeding because that is what caused the profound Anemia 8 months ago of 6.5 hemoglobin and 3 days in ICU with 4 blood transfusions. The bleeding had stopped and the ulcerations mostly healed before leaving the hospital and up until recently the Anemia had almost completely resolved.

But whenever I see black stool ever since I get very concerned, especially that I have felt a sudden increase in symptoms, although not nearly as severe as before. Before I could not even stand up without blacking out.

I am concerned that the Mucinex could have aggravated the previous ulcerations that were found, or had some other type of effect that could have caused a mild worsening of the Anemia. The first bleeding did cause profound Anemia very fast. However this time there was no Aspirin and I felt increased symptoms of Anemia soon after increasing the Mucinex.

Even if a drug is considered a small risk, when there is history of severe bleeding like I have, that is why I am asking if Mucinex could cause any chance of bleeding or worsen bleeding or Anemia of another cause? And also consider that I was using Mucinex at the same time as the Aspirin when I had the life threatening bleeding.

So you are saying that as long as my stool is only green then if there were any bleeding it would a tiny amount?

** I am sorry if any of this is repetitive but these are potentially very serious issues considering my recent history. I have very limited money to pay to see doctors so that is why I am on here with an unlimited subscription. Please forgive the length.


Your questions are welcome and I share your concern especially with the serious medical history of bleeding due to aspirin. I can understand, that this can be a worrying situation.

Mucinex has a very low chance of causing bleeding in a normal individual. Even with a history of significant bleeding, chance would be too low. But since you are using it for long duration, the use should be stopped. Despite the very low chance, in a particular individual, the adverse effect may be not predictable.

You can visit one of the centers run by the Health Resources and Services Administration, they offer affordable quality healthcare to people with insurance issues.

You can find a health center near you by clicking here :

Since your stool is green, chance of bleeding is likely to be tiny or not at all.
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Customer: replied 4 years ago.

I have a few follow up questions.

It has been hard to figure out what is causing what but there are other factors involved here that could be causing many of these symptoms.

The worst of the symptoms actually seem more due to electrolyte imbalance as I have become extremely sensitive to at least sodium and potassium, sometimes calcium and magnesium. I have had similar issues in the past and they were usually either due to dietary deficiencies or not replenishing enough electrolytes after long periods of excessive sweating and exercise.

We have recently had a heat wave with several days well over 100 degrees and I did exercise hard those days. The day after the heat wave was when these symptoms became overwhelming so it seems a few days of heat exhaustion might have been the catalyst that put things way over the top.

I have since done some more reading and have seen mentioned that low blood sodium (130), low blood potassium (134), low Co2 (20), high WBC's (11), and low lymphocytes (4) are common indications of heat exhaustion or stroke.

Now I often feel symptoms of nausea, dizziness, breathing difficulty, increased blood pressure, rapid but weak heart rate, excessive thirst and urination, muscles spasms and cramps, and a few times even passed out. They usually continue to get worse until I take or eat more electrolytes. Potassium and magnesium have seemed to help the most.

Also for the last several months I have been working out very hard trying to lose weight and recover from the past severe Anemia of 6.5 hemoglobin. I was eating a very high sodium diet because I lose a lot from excessive sweat and would get severe cramps and dizziness otherwise (I also regularly show a thick ring of salt on my shirt after working out), and cut carbohydrates and increased protein to about (40% protein, 40% carbs, 20% fat). I have been eating lots of protein and was gaining muscle so I seem to be getting enough calories but I don't think enough electrolytes. I have also read that high protein can affect electrolyte balance because of affecting the kidneys.

Do you think that heat exhaustion could be a major part of this and I could be experiencing residual symptoms of that and electrolyte imbalances?

Could heat exhaustion or related electrolyte depletion possible explain the low hematocit, low rbcs, low hemoglobin, and RDW? The blood work was done the day after the heat wave 5 days ago so I don't know any of the current values.

Hello and welcome Brandon,

Heat exhaustion and resultant electrolytes can explain all of your symptoms and abnormal investigative findings too. Here, you have to take caution to avoid doing excessive physical activity and also take caution to replenish the electrolytes by drinking adequate fluids like fresh fruit juices, coconut water, vegetable broths, Gatorade, Pedialyte and sports drinks.
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Customer: replied 4 years ago.

Could heat exhaustion or related electrolyte deficits possibly explain the Anemia - low hematocit, low rbcs, low hemoglobin, and RDW?

Or could the recent diet have caused this?

Those values were hemoglobin 12.6 down from 14.7 in May, hematocrit 38, RBCs 4, RDW 10.

Another related topic

You are trained in sports medicine?

If so could muscular glycogen depletion increase potassium losses in sweat?

I ask because during those two days my workouts focused on working my arms and quadriceps to seeming glycogen exhaustion. Perhaps that might explain the sudden sodium sensitivity if I lost a large amount of potassium over several days from the excessive sweating and probably heat exhaustion as indicated by the low blood values.


The low hemoglobin, RDW, RBCs, hematocrit usually have some concomitant causes too apart from electrolyte imbalances, but as we discussed, these may be affected by the water and electrolyte imbalances. Though an hemoglobin 12.6 down from 14.7 in May, hematocrit 38, RBCs 4, RDW 10 would not ring the alarm bells. I would just advice you to avoid excessive physical activity and replenish the fluids and electrolytes and than get these repeated after two weeks. Glycogen depletion may affect the potassium losses in sweat. But body has controlling mechanism for everything. Usually the potassium level would not fall to the alarming level due to body's own protective phenomenon which will release the potassium reserves in the conditions like excessive physical activity and hot weather. Thirst is another mechanism which demands to replenish the fluid and electrolytes.
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Customer: replied 4 years ago.

I have a few more follow up questions. I likely did have heat exhaustion at least, but it does not seem to explain why my hemoglobin and other values decreased.

I was reading over my medical records and saw that I had been diagnosed with distal esophagitis back when I was in the hospital. At the time I thought it had been caused by the aspirin and would heal up after stopping the aspirin.

I have been laying flat most of the time since I have been recovering from the Anemia, except when I would exercise. When I would take the Mucinex-D I would be laying flat and would often break up the pills into smaller doses and crush them and swallow them because it is usually too strong. It seems that I often would not swallow them all the way because I was laying flat. Often times I could feel a slight warm sensation in my throat but it was never painful so I never paid much attention.

If I was not swallowing the drugs all the way because of laying down and the Mucinex or pseudoephedrine released too quickly could the effect on thinning mucus (or other effects) leave my esophagus, stomach, GI tract more vulnerable to irritation and bleeding? Or if the drugs themselves are acidic or abrasive could that have an effect of bleeding?

If so could that explain the decreased hemoglobin and other low values?


These medications are likely to cause acid erosion or can be responsible for the anemia. Your symptoms are likely due to gastroesophageal reflux disease (GERD) and anxiety. Following measures can be helpful;

1) antacids; Maalox

2) acid blocker; Prilosec

3) loosing weight, if overweight.

4) avoiding alcohol, citrus fruits and juices, chocolate, and tomato based products

5) avoiding large meals. Eat 5 small meals in a day.

6) wait three hours after the meal before you sleep.

7) elevate head end of the be by 8 inches.

Following also would be beneficial

A. Herbs;

1) Cranberry
2) Peppermint

B. Nutrition and supplements;

1) Multivitamin; vitamins A, C, E, the B vitamins, and trace minerals, such as magnesium, calcium, zinc, and selenium.
2) Probiotic supplement
3) Omega 3 fatty acid
4) Avoid; cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.5) Also avoid; white breads, pastas, and especially sugar, red meats,
6) Eat lean meats, cold water fish, tofu, beans, olive oil

Customer: replied 4 years ago.

I had previously thought I could rule out GERD because I have none of the main typical symptoms. I have no pain, heartburn, or bloating.

The only symptom I felt was a slight warm sensation at times when I did not swallow the pills well enough. I also felt that when I was taking the Aspirin 8 months ago. Otherwise I have never had issues with heartburn or pain in my throat or stomach.

However if the medications could have been causing temporary increased acid erosion or other irritation and the Anemia, then will the damage likely heal since I have stopped taking them?


The symptoms of GERD are many times very subtle and typical symptoms are absent. Since you have stopped the medications if there was any adverse effect due to them would definitely heal and resolve spontaneously.
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Customer: replied 4 years ago.

I have some more questions I hope you might be able to help with.

Since you are experienced with exercise medicine I am hoping you might have advice in regards ***** ***** exercise component of recovering from the Anemia. Aside from iron and sufficient nutrition, nothing has offered more improvement for all of my symptoms than exercise, especially the breathing difficulty.

I can force myself to exercise very hard for considerable time but I get much more easily out of breath now, and the recovery from the exercise has been far more difficult than the exercise itself. I feel extreme appetite for up to 24 hours after even just 20 minutes of interval jogging. I have read that the less oxygen is available during exercise (i.e. the more out of breath you are) the more rapidly muscle glycogen is depleted and that I am likely experiencing exercise induced hypoglycemia from glycogen losses. Not to mention the increased protein needs from muscle breaking down.

I have been tested for reactive hypoglycemia years ago with a high over 200 and a low of 31. However as long as I could maintain a high level of fitness the symptoms were only very minor. With this huge decline in fitness from the Anemia and subsequent bed rest deconditioning it has become a highly debilitating issue.

Are you familiar with exercise science in regards ***** ***** glycogen and how to prevent post-exercise hypoglycemia?

If so what advice can you offer to deal with this extreme appetite after exercise without gaining fat?

What types of exercise are best to improve the breathing difficulty caused by Anemia? I have heard Interval training yields the quickest results but again with that type I get the most out of breath and experience the most intense increase in appetite afterward.

Hello and welcome Brandon,

Exercises do help in importing anemia by stimulating the formation of the red blood cells. This is mediated by erythropoetin formation which in turn ask the bone marrow to form more RBCs.

The best exercises in your case would be initially brisk walking, mild jogging and road cycling. Swimming too would be helpful. Gradually you can increase the duration of the exercises and more strenuous exercises or sporting activity can be started, later. Since you have breathing issue; so split your exercises in 10 minutes of two segments, so it would become total 20 minutes but would be more effective and would not cause muscle breakdown. An increased appetite is a good sign and I would not be worried about it. If you eat fresh fruits, fish, egg white, brown bread, vegetables and green salads without dressings, increase of weight would not be the issue.

Small duration exercise sessions help in preventing post exercise hypoglycemia. You may drink sports drink during the exercises. Thus you are right about the interval training and exercises remaining to be aerobic than turning in anaerobic exercises, by it. The best exercises would be swimming and road cycling / static cycling initially to start with.
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Customer: replied 4 years ago.

The excessive appetite has actually been very bothersome because after the exercise it just seems like no matter how much I eat I still feel pronounced hypoglycemia symptoms - weak, lightheaded, shaky, very hungry. It usually takes 24 hours of greatly increased appetite before these symptoms decrease. And then when I exercise again it starts over again. Eating a higher percentage protein diet has been essential because if I don't, carbohydrates alone just make me even hungrier.

When I was in much better condition I could exercise much harder, and much longer, with much less appetite. I know insulin sensitivity plays a big role, and also the more oxygen you have in your body the more readily your body can burn fat rather than carbohydrates during exercise and at rest.

When I am in such awful shape is there no way around having to increase carbohydrates to fuel the exercise?

I have been drinking a small amount of juice and sea salt during exercise but I am very concerned about increasing carbohydrates as I have gained weight so easily in the past. I have lost over 60 pounds in the last 18 months but it was extraordinarily difficult and I had to make huge strides in improving fitness before I could lose weight.

Also it has been almost impossible to find a primary care MD that understands reactive hypoglycemia. I was diagnosed years ago by a past MD but most doctors since then seem to dismiss this condition when it in fact can be highly debilitating. It is extremely frustrating.

Do you have any suggestions for how I might be able to find a primary care MD that understands reactive hypoglycemia?


Best way to deal with excessive appetite is to start the exercises very gradually. So you just start with walking for a week, and that too for a small distance and than very gradually increase it and switch to more aggressive physical activity only after 4-6 weeks or even later. A burst activity is less rewarding and many times harmful. It is heartening that you have lost a significant amount of weight. Thus your understanding about the various foods and their components and best eatables for you is very good. So go by your own knowledge and what has worked for you for the dietary measures. A usual diet recommendation is;


1 Cup Cooked Oatmeal
Omelet (3 Egg Whites, 1 Slice Cheese, 1 Cup Broccoli)
Green tea
Orange or apple


Light Tuna one can
Orange or Apple
3-4 slices of whole wheat bread
Water or Diet Soda


Brazil nuts


One cup whole wheat pasta
Two chicken breasts
One cup of cooked cauliflower
Half Cup Marinara Sauce

The general dietary advice would be;

1) Dietary fiber; Soluble fiber is present in foods such as beans, oats, barley, and fruits and vegetables.

2) Phytosterols; Phytosterols are present in small amounts in nuts, seeds, and vegetable oils. There are many products on the market that contain phytosterols for total- and LDL-C lowering. These products are orange juice, yogurt, margarine spreads, salad dressings, breads, cereals, milk, and granola bars. Phytosterols also are available in soft-gel pills.

3) Soy protein is healthy.

5) Alcohol; if one takes, limit it to 20-30 ml per day.

Following dietary pattern may be helpful;

1) Red meat in low frequency and amounts

2) Minimally processed seasonally fresh foods

3) Less than five eggs per week

4) An abundance of plant foods; fruits, vegetables, potatoes, breads, grains, beans, nuts, and seeds

5) Olive oil as the principal source of dietary fat

6) Fresh fruits as the typical daily dessert

7) Wine in low to moderate amounts; two glass per day for men.

Customer: replied 4 years ago.

Dr. Phophalia,

It has been such an enormous challenge to deal with so many health problems simultaneously as they all strongly affect each other. I was hoping you might have some advice for the blood sugar issue. I have done a search on here and have seen you post information about reactive hypoglycemia in the past so I hope you can help.

I do not know if that is the most appropriate name for my condition as most doctors dismiss the condition, unless someone is also showing clearly diabetic glucose readings.

At various times I have shown very high readings (over 200) and very low readings (below 40) but it much more often tends to stay on the low end of normal. I often feel symptoms of low blood sugar even when it is in normal range (but usually low normal). It is my understanding this is because of overproduction of insulin due to reduced insulin sensitivity.

I have heard this condition called postprandial syndrome, reactive hyperinsulemia, and reactive hypoglycemia. Most doctors have tended to dismiss these terms even though it is a highly debilitating condition.

The excessive appetite is the most disturbing symptom and is accompanied by very frequent hypoglycemia symptoms. I have seen still elevated insulin levels a few hours after eating, but fasting insulin is within normal range so insulinoma is unlikely. Insulin always seems to go too high in response to eating, then glucose goes too low or drops too far, I need to eat more, and eating more again triggers too much insulin. It is like a vicious circle.

Whatever you want to call it I have always been much more sensitive to carbohydrates and blood sugar fluctuations than the average person. I have always had to maintain a higher protein percentage in my diet and maintain a very high level of fitness to be symptom free. When I am in great physical condition the symptoms almost completely go away. Most in my family are exactly the same way so it is genetic.

However when I lose fitness as I have very much with the Anemia and deconditioning I am again highly sensitive to carbohydrates and blood sugar swings. Sometimes I feel so weak I can barely stand up until I eat more carbohydrates balanced with protein. I have not been able to find a doctor yet that is sensitive to these issues.

Do you have any recommendations for how to find a primary care MD that would understand these issues?

Do you have suggestions as to how to introduce this topic, or convince a skeptical/less informed physician?

What is the most widely accepted term for this condition that a physician is more likely to understand?

Besides higher protein diet and increasing fitness do you have any other advice for dealing with this condition?

It has been incredibly frustrating to have this highly debilitating condition, knowing full well there are plenty of doctors out there that do understand it, and then to be told often that it does not exist.

I know there are plenty of holistic physicians that understand this condition but I have found it very difficult to find a primary care MD that can be the doctor on call for emergencies and has hospital privileges. When I was in the hospital for example I was not allowed to eat any protein for 2 days, which caused severe blood sugar symptoms.

I really need to find a primary care doctor that is sensitive to this issue that can be in my corner in emergencies.

Hello Brandon,

Let us first talk about the reactive hypoglycemia and associated symptoms, you have been experiencing. Reactive hypoglycemia can be idiopathic (no exact cause ascertained), unfortunately, due to intestinal problems, or a result of congenital enzyme deficiencies. Very rare cases of idiopathic intestinal hypoglycemia occur in patients who have not had gastrointestinal operations. So I agree that your doctors should consider this entity especially your long observation and research backs this up.

Congenital enzyme deficiencies are;

1) hereditary fructose intolerance,

2) galactosemia, and

3) leucine sensitivity of childhood. Leucine provokes an exaggerated insulin secretory response to a meal and reactive hypoglycemia in patients with leucine sensitivity of childhood.

Other causes of hypoglycemia are;

a) Autoimmune hypoglycemia: Insulin antibodies and insulin receptor antibodies

b) Hormonal deficiencies like Adrenal insufficiency and Hypopituitarism.

c) Starvation

I would suspect leucine sensitivity in you. Try to avoid the leucine rich foods and see, if this helps. Please see this resource about the leucine food;

It is difficult to suggest you a primary care doctor as I am not aware of doctors in your region. Local references are best for that purpose. But I strongly suggest to get a referral for a gastroenterologist, who would definitely understand these issues and would not dismiss your very right observations, Meanwhile, I would also suggest you following measures which will keep you relaxed and anxiety free;

1) Group sporting activities

2) Relaxation training and biofeedback.

3) Hypnosis

4) Acupuncture and acupressure

5) Yoga

6) Meditation

Dr. Arun

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Customer: replied 4 years ago.

I do have fructose and lactose intolerance but I don't see how that is connected since I don't eat dairy and very little fruit? I do get stomach aches from significant amounts of fructose and lactose. And I know the hypoglycemia symptoms worsen over time if I eat too much fruit, but that holds true for increasing any kind of carbohydrate.

When I am not highly physically fit something seems to trigger excessive insulin no matter what I eat. However as I said the higher degree of fitness I can attain the less significant the hypoglycemia symptoms become, and it seems due to increased insulin sensitivity, reduced insulin levels, and increasing oxygen levels in the blood, which enables more fat oxidation to be used for fuel rather than glucose during exercise and at rest.

The challenge is trying to reach that level of fitness. Right now DURING exercise I feel dramatic improvement for up to 2 hours, which I have read is due to the exercise forcing temporary lowered insulin and increased insulin sensitivity - the so-called "afterburn" effect. And that over time these effects become more consistent and long term. That has certainly been my experience.

However every time I exercise, after this temporary improvement wears off I feel a dramatic temporary worsening of the excessive appetite and hypoglycemia symptoms. It is often overwhelming and sometimes I can barely even stand up unless I eat small amounts very frequently. Drinking a sports drink to replenish glycogen, and protein shake to replenish muscle protein does help somewhat but not enough.

It is this recovery period between exercise that I need help. If I can figure out some way to make it through the recovery period without having to deal with these almost constant hypoglycemia symptoms I would be well on my way to recovery.

Are there any supplements or drugs you can recommend that might help suppress this excessive appetite, or would increase insulin sensitivity, lower insulin levels, increase oxygen levels, etc?

Also, why is it so difficult to find a doctor that even acknowledges reactive hypoglycemia? Even the gastroenterologist and endocrinologist just dismissed my suggesting it outright, even though I have blood tests showing very low glucose at times, and the experience of an entire lifetime of dealing with this condition.

I am not sure why the doctors dismiss the condition. I agree that it is not common but it is not exceedingly rare and with your symptoms and investigations, some, consideration should be there to recognize the entity.

The best way to decrease your appetite would be avoiding burst of activity. An exercise of around 10-15 minutes at a time and no repeat atleast for 2 hours would be the way to go initially. This will take care of the present symptoms and later on in long term, the body would set the physiological parameters differently and even a football game of full duration would not trigger the increased craving for the food in an year of so.
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Customer: replied 4 years ago.

We spoke earlier about my issues with electrolytes and exercise.

I have had two more episodes of severe seeming hyponatremia after several consecutive days of excessive sweating during exercise. I am trying to figure out how to prevent this from happening again as these episodes have been so intense I have blacked out unconscious several times with other almost overwhelming symptoms.

It seems to come on suddenly about 1-2 hours after finishing exercise. I have continued to try to take extra sodium and water before and during exercise but it does not seem to be enough when I have had these episodes.

How much sodium is stored in the body? How long does it take to restore those reserves, and how much sodium is needed, after an episode of severe hyponatremia?

Is there a way to determine an approximate amount of sodium I would need to supplement with and how much water to mix it with? I want to try and figure out a good estimate of how much I actually lose for a certain amount of water weight that is lost as sweat.

Thanks Brandon, for the follow up.

Following condition can cause sodium deficiency;

1) High blood sugar (diabetes)

2) Hyperlipidemia (high cholesterol and triglycerides)

3) Paraproteinemia; increased proteins in the body

4) Medications like diuretic

5) Kidney diseases affecting renin-angiotensin system

6) Antidiuretic hormone (ADH) secretion

7) Salt-wasting nephropathy (kidney disease)

8) Liver cirrhosis,

9) Congestive heart failure,

10) Nephrotic syndrome,

11) Nonsteroidal anti-inflammatory drug (NSAID) use may increase the risk of development of hyponatremia

12) Excessive exercises

Investigations to assess the causes for low sodium are;

1) Urine osmolality

2) Serum osmolality

3) Urinary sodium concentration

4) Serum albumin,

5) Serum triglycerides,

6) Serum protein electrophoresis

7) Thyroid-stimulating hormone (TSH)

8) Serum cortisol levels

9) Serum uric acid levels

The treatment is dependent on the severity of deficiency of sodium, mode of onset and cause. If it is severe and sudden, intravenous saline drips is required, otherwise oral increased table salts with periodic monitoring of the blood levels of the sodium and management of the cause takes care of the deficiency.

Low sodium and history of low glucose / reactive hypoglycemia warrant hormonal tests and the tests mentioned above.

Customer: replied 4 years ago.

I already read about the conditions you cited and have had most of the tests you mentioned, most of them coming back "normal". The glaring abnormaility was low sodium after a few days of excessive heat. The hyponatremia is almost certainly primarily due to excessive sweating and overhydration from sweat losses during exercise or heat.

I have always had the problem of sodium loss from excessive sweating to some degree but now with my other conditions it is harder to manage. When I do not exercise it is much easier to manage but I must exercise to recover from my other conditions.

Would you please answer my original questions:

How much sodium is stored in the body? How long does it take to restore those reserves, and how much sodium is needed (dosage in grams), after an episode of severe hyponatremia? How much water should I consume per gram of sodium to ensure enough sodium but to not dilute the blood plasma further and worsen hyponatremia?

Is there a way to determine a good estimate of how much sodium I actually lose for a certain amount of water weight that is lost as sweat? I want to avoid overhydration and not taking in enough sodium.


The total sodium is about 24 gms in an adult man. The severe hyponatremia may need 2 gm of sodium diluted in 150 ml of water every hour for 3-5 hours to correct it.
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Customer: replied 4 years ago.

These seeming episodes of hyponatremia have occurred pretty suddenly about 2 hours after sweating heavily from exercise, and urinating out the large amount of extra water I drink and seem to retain during the exercise to make up for sweating. I have taken extra sodium with the increased water during exercise but it seems to have not been enough.

The symptoms have been severe weakness, pale skin, collapsed veins, cold extremities, sudden low blood pressure, very weak and reduced pulse, and near unconsciousness. These symptoms all reversed within about 2 hours of taking lots of sodium, water, and fruit juice. I don't know how much sodium I took, but it must have been at least 4-6 grams after measuring the container today.

So if hyponatremia is severe enough to nearly cause unconsciousness, then 6-10 grams of sodium over 3-5 hours is needed to restore levels for any one episode?

Since you say 24 grams total sodium in the body, then where is the other 14-18 grams stored? Is that supposed to be used up as reserves when the sodium blood levels fall? Do those reserves also need to be replenished after an episode of severe hyponatremia?

I want to make sure I am completely replenished before I try exercising again after having severe episodes 2 days in a row. It would be very dangerous to be out walking somewhere and collapse unconscious because of not having replenished enough sodium.

Brandon, 6-10 grams of sodium over 3-5 hours is usually good enough. The dose titration has to be done on the basis of your symptoms. Once the symptoms reverse completely, you may stop the extra salt.

The sodium stays in the blood, in the cells and fluid in between the cells (which forms various organs, muscles and other tissue). This stored sodium would not come to rescue the symptoms immediately as it takes some time to come into the play. Meanwhile instead of banking on the stored body sodium it is good to supplement it from the outside. If your symptoms have disappeared completely, this is a good indication that sodium is restored.
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Customer: replied 4 years ago.

I had an even worse episode of seeming electrolyte imbalance symptoms last night and it was even more difficult to recover from.

It does seem low sodium is a major part of this judging from how much it has helped but I am also concerned potassium could be playing a role since I am not taking in nearly as much potassium as sodium. I have read potassium is also lost in large quantities with sweat, exercise, diarrhea, etc.

Last night I also had 6 watery bowel movements in about 8 hours and it seems to have been caused by taking too much Magnesium. I had severe symptoms for many hours - weak heart beat, severe weakness, shortness of breath, blood pressure fluctuations, pale skin, near fainting. I had to take a lot of sodium, water, and fruit juice before the symptoms finally improved. I don't know which of either potassium from fruit or sodium finally did the trick.

How much potassium and sodium is typically lost from such a severe episode of diarrhea? How can I replenish those safely?

How much potassium is lost from exercise and excessive sweating?

Is there a way to take in larger amounts of potassium without having to consume large amounts of carbohydrates? I gain weight very easily from increasing carbohydrates. For sodium I can just take sea salt.


The exact calculation of potassium or magnesium is very difficult in an exercise or a diarrhea episode. As you know, potassium and magnesium have a narrow normal range. The only way to assess them is by the blood work. No exact prediction of the loss for them can be done, in this regard with the exercise activity / sweating amount or by the stool volume. The best way to replenish them is by the;

1) Pedialyte
2) Gatorade and other sports drinks
3) Coconut water
4) Fresh fruit juices
5) Citrus fruits
6) Vegetable broth.

These would not increase your body weight.
Customer: replied 4 years ago.

Actually I do gain weight very quickly from low glycemic carbohydrates such as with the sources you mentioned. I gained several pounds of fat in only a week recently when I increased carbohydrates. It was very frustrating after having worked so hard to lose weight.

Are there other safe ways to increase potassium? Are there low carbohydrate vegetables that are high in potassium?

Is potassium chloride from salt substitute safe? I have read mixed opinions. In the US we can only buy 99mg tablets of potassium supplements. Are these safe?

Potassium 99 mg tablets are not safe as these may increase the potassium dangerously. Coconut water has a very low calorie and low carbohydrate content and would help in your electrolyte imbalances.
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Customer: replied 4 years ago.

These electrolyte symptoms have continued to be severe but I think I might see a pattern emerging. The symptoms do actually seem to become the worst after consuming foods with higher sodium. And before each of the episodes I had eaten very high sodium meals right after exercising with heavy sweating.

The initial symptoms I feel after increasing sodium foods are weaker and slower heart beat (as low as 45bpm when symptoms severe), high blood pressure, dizziness, breathing difficulty, weakness. They seem to worsen the more sodium I eat unless I drink a lot of water.

Before these episodes started I was much less sensitive to higher levels of sodium so I am wondering if these symptoms I are due to potassium deficiency being aggravated by high sodium. I do not have blood levels for potassium currently but since the symptoms are the same as when it was low before, but now more intense I assume it must be lower now.

Can these symptoms I feel when increasing higher sodium foods be related to potassium deficiency? Does potassium deficiency cause sodium sensitivity or sodium retention?

If so how much potassium would I need to replenish potassium enough to reverse the sodium sensitivity as a rough guess, and how long would it take (days, weeks, or months)?

I have tried coconut water several times it has seemed to help but it is hard to tell what is due to what. Fruit juice on the other hand actually seems to frequently increase urination and worsen the dehydration, especially when I am already very dehydrated. Could this be because of the high sugar content causing rapid glucose spikes and triggering increased thirst and urination in a similar way that dehydration triggers hyperglycemia in diabetics?

Hello Brandon,

Potassium deficiency can retain sodium to some extent as body wants to exchange the positive ion with another positive ion. Potassium supplements usually are avoided unless the potassium deficiency is established and confirmed by the blood levels. The 60 mmol of potassium which is about 2350 mg, of elemental potassium usually is sufficient enough per day, which can replenish the low potassium in about couple of days to compensate back the deficiency. A bottled fruit juice have increased sugar and thus causes increased urination due to high osmotic pressure (as in diabetic as you mentioned). The fresh fruit juice is not likely to cause that problem.
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Customer: replied 4 years ago.

I really need to figure out what is causing the excessive urination because it is continuing to cause frequent severe dehydration.

If I don't keep drinking water and taking electrolytes I become so dehydrated I can't even stand up without blacking out. This also keeps me from being able to sleep more than an hour at a time because I keep waking up with overwhelming dehydration symptoms. The symptoms include severe lightheadedness and fainting when upright, painful muscle cramps and twitching, extreme thirst, very fast but weak pulse, very high blood pressure (180/110). shivering and pale skin, collapsed veins. Normal blood pressure is about 130/80.

This all did seem to start after a few months of very high sodium high protein diet, and the first few episodes of severe dehydration occurred not long after sweating heavily and having consumed very high sodium meals (5-10 grams). I was also on a low carbohydrate diet for months and was thus consuming much less potassium. Would this very high salt intake and low carbohydrate diet over time cause severe potassium depletion?

I have read that potassium deficiency interferes with proper kidney function and can cause excessive thirst and urination. Do you think that is what is going on with my excessive urination?

If so, with such severe seeming potassium deficiency symptoms, worst case scenario, how long will it take of extra dietary potassium to start seeing improvement, particularly with the severe dehydration from excessive urination?

How much sodium do I need to be consuming while replenishing potassium because I know sodium antagonizes potassium? I know they need to be in careful balance to maintain blood volume but I keep going back and forth between feeling sodium overdose symptoms or low blood volume like symptoms when severely dehydrated.

Hello Brandon,

I am not certain if you were investigated for the sleep apnea or diabetes insipidus which can cause increased urination and loss of electrolytes. An high sodium diet may have caused all of your symptoms (and low carbohydrate diet during that time also may play some role), but the symptoms should not be ongoing. These should get better once you have stopped the high sodium. The potassium usually does not get severely depleted by it and if at all it occurs, this returns back to normal, very fast after stopping high sodium.

Potassium deficiency, increased urination and excessive thirst thus need to look for the diabetes insipidus and other medical issues as following;

A. Polyuria which is defined as a total 24-hour urine volume greater than 40 ml/kg.

B. Nocturnal Polyuria; Urine output normally decreases during the night. This appears to be related to a corresponding increase in secretion of antidiuretic hormone (ADH). As ADH secretion increases, there is increased resorption of water from the kidney tubule, resulting in lower volumes of concentrated urine. The urine output during sleep can be expressed as a percentage of the total urine output over 24 hours if the 24-hour urine output is normal. Nocturnal polyuria is defined as a night time urine output greater than 20% of the daily total in young adults


C. With certain respiratory conditions such as sleep apnea, low oxygen in the lungs can lead to pulmonary vasoconstriction and increased concentrations of peptides responsible for the elimination of sodium in the urine. This can result in increased secretion of water.

The potassium supplements as you mentioned too need a very careful balance with the sodium and doing this on own is difficult and should be supervised by the doctor, especially if there is a documented issues of electrolytes. 2.4 g sodium or 6 g sodium chloride per day with potassium (approximately 90 mmol/d), is the usual recommendation. Citrus fruits and banana are the best bet to replace potassium without causing any adverse effects.

Customer: replied 4 years ago.

I think a big part of the reason it is taking so long to recover from is that I did not realize until very recently that high sodium was likely the main cause initially and was continuing to aggravate everything. I now understand that for many months I was not taking in enough potassium

because of the low carbohydrate diet and high sodium so I don't know how severe the deficiency became over that time.

I have been feeling every symptom they describe for potassium deficiency and very intensely. The several days of watery diarrhea seemed to have been the catalyst for making these symptoms so much worse. Perhaps I lost a very large amount of potassium during that time and perhaps magnesium also.

Another factor that a doctor on here has mentioned and I have read many places elsewhere is that potassium deficiency cannot resolve when occurring with magnesium deficiency. I have long shown symptoms of magnesium deficiency and was actually prescribed magnesium when I was in the hospital from the GI bleeding. I do often feel very strong relief in many symptoms from magnesium supplements temporarily. On two nights recently it actually seemed to stop the excessive urination enough for me to be able to sleep without becoming severely dehydrated. But it does not work every time, perhaps due to inconsistent potassium intake.

In the presence of magnesium deficiency what would I need to do different to replenish the potassium? How much longer would it take to recover from the potassium deficiency with concurrent magnesium deficiency assuming it is severe? How much magnesium should I be taking considering that I have seemingly such severe potassium deficiency symptoms?

I have been taking small amounts of magnesium throughout the day to try to avoid it causing diarrhea and take a little more when I am eating more potassium. But at the same time if I take too much without balancing it with calcium I feel aggravated symptoms of my also calcium deficiency. My food intake of calcium is very low because I can't eat dairy from lactose intolerance. I have issues with easy injury to joints and bones, rotting teeth and sore teeth, and other symptoms that always improve quickly with calcium supplements.

Hello Brandon,

Following are the answers of your questions:

In the presence of magnesium deficiency what would I need to do different to replenish the potassium?

In the presence of both the deficiency, supplements of both are needed.

How much longer would it take to recover from the potassium deficiency with concurrent magnesium deficiency assuming it is severe?

It may take 5-7 days.

How much magnesium should I be taking considering that I have seemingly such severe potassium deficiency symptoms?

Magnesium citrate (OTC) 2 tablets/day; preferably with meals or 2 teaspoons of powder with water per day is the usual recommendation.
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Customer: replied 4 years ago.

I have several more follow up questions.

I have been seeing some improvement in my electrolyte symptoms after having been supplementing with 600mg of magnesium (balanced with equal calcium), and eating a high potassium(4-5grams/day) low sodium (2-3grams/day) diet. Often times the improvement is profound soon after taking larger amounts of the magnesium and potassium foods. This does seem to indicate still pretty severe deficiencies in magnesium and potassium. I experience sometimes overwhelming heart related and breathing problems if I do not continue supplementing magnesium and eating lots of potassium.

These severe symptoms occur especially if I am not very careful with exercise. However exercise has been so critical to treating my other health problems I need to figure out how to continue it without worsening the electrolyte problems.

I have noticed quite a few times recently that when I do more intense exercise or focus on strength training I experience the worst symptoms afterward, and many other symptoms of dehydration - very dry skin, tingly and sometimes itchy skin, dry mouth, increased muscle cramps and spasms, excessive thirst and urination despite drinking lots of water, extreme weakness, and worsened heart related symptoms.

I have read that during intense exercise large amounts of potassium are temporarily dumped in the extracellular space and are readily lost in urine or sweat. Do the muscles re-uptake some of this potassium before it is lost from the body or does it all have to be replaced with diet? Does this loss also occur with magnesium during exercise?

I am trying to figure out if potassium losses from glycogen depletion are more responsible for these worsened symptoms after exercise or it is related to changes in magnesium, calcium, or sodium?

How much potassium could be lost (in milligrams) if the large muscles (arms and legs) are exercised to exhaustion and near glycogen depletion? I am very muscular especially in my arms and legs so I likely have a lot more glycogen and potassium to lose.

Hello and welcome Brandon,

Almost 40-50% of potassium is recovered back by the reabsorption from the extracellular space by the muscles. The loss of magnesium is negligible as it is almost completely reabsorbed.

Your symptoms are more suggestive of potassium and slight sodium deficiency.


About 2200 to 3100 mg of potassium can be lost from the arm and leg muscles alter the intense exercises.
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Customer: replied 4 years ago.

I have a few more questions regarding magnesium deficiency and electrolyte imbalance.

I have continued to supplement with magnesium and the short term improvement in all my symptoms is usually very strong and obvious. Conversely when I do not take enough magnesium I feel greatly intensified symptoms when taking/eating substantial amounts of calcium, potassium, or sodium. I remember a doctor on here saying and my reading many times that electrolyte imbalance will never resolve without adequate magnesium.

I am curious of other dependencies. I am aware that for potassium to absorb into the cells there needs to be sufficient magnesium, and that magnesium is essential for proper calcium absorption, metabolism, and storage in the bones.

Does magnesium absorption depend on any minerals or vitamins for absorption into the body?

Once absorbed into the blood does magnesium depend on any mineral or vitamins in order to be properly absorbed into the cells (like potassium requires magnesium to enter the cells)?

I have read that magnesium is stored mostly in the bones. Is magnesium dependent on any minerals or vitamins in order to be properly stored into the bones?

Hello Brandon,

Using just magnesium without improving the other electrolyte balances would be an obvious reason for limited success with magnesium. Low potassium levels can increase urinary magnesium excretion. Frequent consumption of alcohol, coffee can also affect the magnesium absorption.

Magnesium is very less dependent on the potassium for its entry in to the cell. The competition with potassium or any other electrolyte is minimum.

60% of body magnesium is stored in bone. The storage is dependent on the normal calcium of the blood and bone. If both are normal; magnesium is properly and adequately stored in the bones.

Please see the authentic resource about the magnesium metabolism, absorption and storage;
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Customer: replied 4 years ago.

I have more follow up questions regarding my electrolyte issues.

I have continued experiencing severe electrolyte symptoms - large fluctuations in blood pressure and heart beat, shortness of breath, painful muscle cramps, spasms, and twitching, eye twitching, very dry skin, nausea. The excessive urination continues to cause episodes of dehydration to the extent I become pale and so weak I can barely stand up, unless I continue to replace water and electrolytes.

The muscle cramps, spasms, and twitching have gotten worse, now to the point where I can't exercise at all without severe cramping and frequent involuntary muscle twitching after only just a few minutes. Other symptoms of electrolyte imbalance also now worsen after even minimal amounts of exercise. I also feel chest tightness and worsened shortness of breath often when the cramping is worst, which seems related to the effects of the electrolytes on my heart. I am very concerned if the exercise is actually further depleting my muscles and body of electrolytes and worsening these deficiencies?

Which electrolytes are most responsible for the cramping, spasms, and twitching and that it is frequently all over my body and not just the muscles I exercised - my arms, legs, chest muscles, back muscles, sometimes near my heart, neck? This cramping and spasms seem like important clues to figuring out what is going on. I have never had such widespread and consistent cramping until the past few weeks.

Is it going to continue to worsen my symptoms to try and exercise?

How long would I have to take a break from exercise in order for my muscles and body to replete potassium considering the magnesium deficiency and possibly severely depleted reserves of potassium, magnesium?

I am also very concerned that the excessive urination could be preventing my efforts to replenish my electrolytes, especially potassium?

However as you said, and I have read many places, that low potassium increases urination. How can you replenish low potassium if you are urinating excessively because of low potassium?

I have read that potassium cannot replenish as long as magnesium is low. Could that be why the magnesium supplements continue to have such a strong positive effect? Many times they have actually seemed to lessen the excessive urination significantly. However calcium seems to have the opposite effect and increases urination.

What else can I do to stop the excessive urination? I am not taking any diuretics (unless certain foods or electrolyte supplements are diuretic), caffeine, or alcohol.

P.S. Thank you sincerely ***** ***** more in depth answers on here. Many other experts do not reply as thoroughly as you.

You are very welcome, Brandon.

Calcium is the most important electrolyte responsible for the cramping, spasms, and twitching. A small role can be played by potassium and magnesium. There is chance that these may worsen if keep doing exercises. I would suggest couple of days complete rest. Meanwhile drink Pedialyte and Gatorade. After couple of days or when yours symptoms completely go away; than very gradually you should increase the exercises. I am not sure about your excessive urination. But if you have not been investigated for diabetes insipidus, you may consider it. Only a low potassium is not solely responsible for your excessive urination. Rest for some days may help in replenishing the potassium too as there would not be any additional loss due to exercises.

All electrolytes are closely related. Thus potassium, calcium and magnesium do have interchangeable role and affect each other (excretion as well as absorption). Thus magnesium does have a positive effect. In your case the key would be initial period of rest and than very gradually increasing exercises. A small rest would normalize the electrolytes in the body and gradually increasing exercises would not cause sudden burst changes in electrolytes as you would replenish them by the electrolyte solutions.
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Customer: replied 4 years ago.

I have been very concerned about calcium for some time, and because of my lactose intolerance I get very little from food. My teeth have been slowly rotting despite no sugar and daily brushing, my hair is brittle and has been falling out, my nails are brittle, and I feel joint aches and pains. In addition to whatever other symptoms could be caused by low calcium.

It is very frustrating as you alluded to, that the electrolytes are closely related and strongly affect each other. I have been for weeks trying to figure out how much of each I need because if I take too much of the wrong ones everything worsens greatly. When I get it right then everything improves.

Right now however calcium supplements frequently aggravate many symptoms especially with increased blood pressure and heart rate. When I take more calcium than magnesium my heart beats harder and faster, my blood pressure increases a lot, and I become more short of breath. It also seems to frequently increase urination.

When I take more magnesium than calcium the opposite happens. My heart beats slower, blood pressure drops, and breathing is easier, and most other symptoms improve.

Calcium has had these effects several times in the past and it only reversed after several months of magnesium supplementation. After the magnesium supplementation the calcium began having the normally expected effects of reduced blood pressure and pulse, and sedative like effects.

I have read that excess calcium and sodium can cause or aggravate magnesium deficiency and it does seem that my very high sodium diet, low carbohydrate, high protein, heavy exercise diet might have caused severe magnesium deficiency, in addition to aggravating the longstanding inadequate calcium intake, and then the magnesium deficiency has been aggravating the potassium deficiency.

It seems right now that if I take more than 2:1 magnesium to calcium my symptoms worsen greatly. However that is much less calcium than the recommended daily allowance and if I am deficient I assume I would need more?

How can I supplement with calcium right now without aggravating the magnesium deficiency and other electrolytes?

As I said right now calcium raises my blood pressure, heart rate, worsens the breathing difficulty, and seems to increase urination. Is there no other way other than to wait until the magnesium deficiency improves, and then slowly increasing calcium as that improves?

Brandon. You would need more calcium. Try equal magnesium calcium ratio. This is likely to help. Try calcium rich diet too apart from supplements;

1) Dairy products you have to avoid due to lactose intolerance.

2) Fish with small bones,

3) Dark, leafy green vegetables (mustard greens, kale);

4) Corn tortillas,

5) Calcium-set tofu

The best way would be what you mentioned. First improve magnesium deficiency as small variation in it can cause significant symptoms. Than very gradually increase calcium by diet and slowly increasing dose of supplementation. That would likely to prevent the symptoms you experience.
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Customer: replied 4 years ago.

I seem to keep going back and forth between too high and too low magnesium or calcium. As you suggested I assumed the severe cramps and muscle twitching were being caused by calcium deficiency. The last 2 days I increased calcium/magnesium ratio to about 2/1 and this time actually felt marked improvement in the cramps, felt the more expected sedative effects, and was urinating much less. However today continuing with the increased calcium I felt terrible nausea and increased urination again, seeming symptoms of overdose.

Could the highly absorbable forms of calcium glycinate chelate, and magnesium glycinate chelate be causing too much to be absorbed at once and that is causing my blood levels to fluctuate too much with both, and then my body has to flush it out with excessive urination?

They both have very strong effects and if not carefully balanced the urination seems to increase greatly. And as I said the ratio seems to keep changing as if I am going back and forth between too much/too little of either one. I am struggling to tell how much of each I need.

With the recommended daily allowance for calcium being(###) ###-####g and for magnesium 400-600mg, is that how much we should be consuming or how much needs to be absorbed? I ask because I have read only about 50% of what we consume in food is actually absorbed so that would mean with 1200mg of calcium consumed only 600 would actually be absorbed and used by the body? If not how does this work?

If the required amount to be absorbed is less than RDA, would that mean that the highly absorbable supplements could be exceeding the amounts needed?

Hello Brandon,

The highly absorbable forms of calcium glycinate chelate, and magnesium glycinate chelate may be causing too much to be absorbed at once and that are likely to be causing the levels to fluctuate too much. Ideally, you should not go by the symptoms alone. An occasional blood test to ascertain the levels can give objective data and thus the dose can be titrated accordingly. Meanwhile you may take the calcium and magnesium for 2 days and than skip one day so the increased level experienced may be negated.

You are right that about 50-60% is absorbed usually. But if the blood levels are low there is an increased gradient in the intestine and the absorption can increase up to even 70-80% levels. So need of body also change the gradient in the intestine for the absorption.
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Customer: replied 4 years ago.

So taking 1000mg of calcium for someone not deficient their body only needs about 500mg and does not absorb the rest? Does that mean the recommended intake is for the amount consumed, not absorbed?

So if the supplements are much better absorbed, then it might be more than I can use or store at a time and I am just peeing out extra, along with possibly losing much needed other electrolytes in the process?

Brandon, people who are maintenance dose of 1000 mg need only 500 mg as the rest may not be absorbed. In the intestine there is a gradient system, which dictates the percentage of calcium to be absorbed. Normally it is about 50%. Your taking of calcium would be dependent on the symptoms and the titration of the dose has to be done by the varying symptoms. The increased urination too has to be quantified as sometimes there may be increased frequency of urination but total amount of urine remains same or is not significantly increased.
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Customer: replied 4 years ago.

Hello. We have consulted before about several of my health problems with Anemia, electrolytes, weight problems, etc. Since you are trained in sports medicine I am hoping you can help with advice for a recent knee injury.

Since exercise has been critical to improving all my other health problems this injury has been quite devastating to my progress as now I can hardly do any exercise without pain on my right knee.

I need help diagnosing and treating this injury at home. I am new to these types of injuries so I need as much information as you can provide, in regards ***** ***** home treatment, by how much and how long I need to be off of it, and rehabilitation exercises. I will happily answer follow up questions to help with diagnosis.

It occurred after running about 2 weeks ago after having been mostly bedridden for well over 6 months and having lost a lot of quadriceps muscle. For months I had been building back the quadriceps strength I had lost with squatting exercises with no pain or injuries. But when I tried running outside 2 weeks ago this present injury occurred and it has been too painful to exercise or lean too much on my right knee ever since.

Initially there was more swelling and it was painful to bend my knee all the way back. The swelling has decreased since then, none at all if I stay off it completely, and I can now bend it all the way back without pain. At rest and when walking I usually do not feel pain unless I recently aggravated it with exercise or put too much weight on it.

The pain occurs when I lean on my right knee, twist it, or try to do weight bearing exercise on it. The specific areas I feel pain are on the left and right side of my right knee below the kneecap, and right above and below the kneecap in the center. I usually do not feel pain at all 4 areas at the same time and can't really tell which area hurts the most.

It has been slowly improving over the last 2 weeks as I said as long as I stay off it, with less pain and less swelling, but as soon as I try to exercise on with too much weight the pain and swelling increase again and take about a day to improve.

What type of specific injury does this sound like?

What can I do for home treatment?

I have read ice, heat, compression, and elevation are the main treatments but the information is sometimes conflicting and I don't know when each of these treatments should be applied.

How do you know when heat or cold is best, ***** ***** how long, how often?

When will I know when it is safe to start exercising it again to rebuild my quadriceps?
What exercises can I do in the mean time to minimize quadriceps muscle loss?

I have lost a lot muscle around my leg and continue to lose leg muscle as long as I can't exercise my right knee so I am very concerned that if I lose too much muscle it is going to be much more difficult to recover from this injury without making it worse.

Hello Brandon,

Following are the answers;

What type of specific injury does this sound like?

Primarily muscular, but tendons do sprain and there is a mild bursitis too.

What can I do for home treatment?

Initially rest is best. Than once the pain is slightly better start with just wal*****, *****sk walking, stretching exercises, exercises against resistance and exercises with weight. All of this can take almost 6 weeks and are added gradually every week according to the improvement of pain.

I have read ice, heat, compression, and elevation are the main treatments but the information is sometimes conflicting and I don't know when each of these treatments should be applied.

All these are done initially for 3-5 days depending on the severity of injury but may need continuation if the pain has not significantly improved.

How do you know when heat or cold is best, ***** ***** how long, how often?

Cold is done only for 3-5 days, especially if there is a swelling persisting. If there is no swelling heat may help.

When will I know when it is safe to start exercising it again to rebuild my quadriceps?
What exercises can I do in the mean time to minimize quadriceps muscle loss?

Pain is the guiding factor. See this resource and add exercises gradually which do not cause pain;
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Customer: replied 4 years ago.

Thank you very much for answering each question.

You said to use pain as my guide. Since I have a very high pain tolerance it is very difficult to judge how much exercise is too much.

Right now almost any exercise that puts pressure on my kneecap causes pain. Squatting even only slightly on my bad knee causes the worst pain. How much pain would be considered too much and would aggravate the knee injury rather than help it?

During the first week I continued doing exercises that only caused a little knee pain, but the swelling and pain only started improving when I stopped doing all exercises that caused any pain. However I also did not realize that I needed to keep my knee elevated and blood was pooling in it all day because of my deconditioned circulation. I also did not realize that I needed to ice the knee.

Do you think it was more the lack of elevation and icing, or the exercises that were causing it to not improve initially?

Since the knee did not start improving until I stopped all exercise that caused any pain, does that mean I have to avoid those exercises completely until I feel no pain at all from them? Or do I do them only at a level of intensity/duration before any amount of pain sets in?

Calf raises have been the most aerobic exercise I can do right now without causing direct knee pain, but during the first week they seemed to worsen the knee swelling. I would feel normal mild muscle burning sensations on the leg muscles on the side of the front of the lower leg up to the knee area. Could overworking those muscles have caused the seeming increased knee swelling or does it seem more like it was the calf raises aggravating the knee injury directly?

And if any of the other exercises were to increase swelling after the exercise, despite not feeling knee pain during the exercise, would those worsen rather than help my knee heal?

For example I have read that flexing the quadricep muscles at rest will minimize atrophy, but even that causes some pain on the top of my knee cap. Should I not do those either?

You are very welcome, Brandon.

Discomfort or mild pain is allowed. More pain than that; prohibits those particular exercises. Please remember that pain is our protective phenomenon which says not to do those things which are painful as that guards or prevent the further injury. Squatting is considered as a significant exercises (as you carry whole body weight on the knees) and is last exercise which is done, when one is pain free.

All the factors actually (more exercises and not elevating or icing) are likely to contribute in the initial aggravation or no improvement.

Continue to do the calf raised and avoid running or jogging for some time. It is difficult to exactly say, what aggravated your pain initially, but that is immaterial now and more than the swelling, pain would be the best guiding factor for your upgrading or increasing the exercises.

Flexing the quadriceps, as you read is the best to prevent the atrophy and called as quadriceps drill. If pain is mild, you may continue it. A pain during the exercises do confirm the injury to the muscle fiber and once the pain goes off, this mean, healing has completed. Than you can gradually strengthen it. Please remember; strengthening may take almost 3 months.
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Customer: replied 4 years ago.

I have only just started icing or heating the knee for the past 2 days, 2 weeks after the original injury. Both decrease the pain, the ice seems to decrease the swelling better, but my main concern is which will make it heal the fastest?

It seems most articles say heat is better because it increases blood flow to the joints, increasing nutrients that reach the injury. But other articles say that cold decreases the swelling and inflammation which improves healing. I have more often seen it mentioned that ice should be used daily until there is no more swelling and then heat when there is no swelling, but if swelling persists ice should continue until it is gone completely. Could you please try to clear up this confusion? Should icing continue until there is no more swelling? When exactly should heat or ice be applied, for how long and according to what symptoms?

I am sorry if I am repeating anything. It is just so confusing with so many conflicting articles online. I really need to get this right so I don't re-aggravate this injury again.

If pain should be my guide rather than increased swelling, does that mean I should ice my knee any time there is more swelling caused by exercise? Are you certain that exercises that do not cause pain, but do increase swelling are not going to aggravate the injury?

Should I be wrapping up my knee or using a brace until the pain and swelling are gone? Is one better than the other?

And I keep seeing "inflammation" and "swelling" used seemingly interchangeably in articles. What is the difference and how do you tell which is going on and how to treat them differently or the same?

Hello Brandon,

Heat is more soothing after the two weeks and is likely to be more helpful in healing than the ice.


What is my experience; I use ice for not more that 5-7 days, regardless of the swelling. More than 90% of the time, swelling cease to increase after this duration. And thus I feel there is no role of Ice. Swelling onlyaggravates after this duration, if there is increased exercise, commensurate to the strength of the tissue. So if you do optimum exercise, swelling would now not increase and only heat is necessary after two weeks.


If there is no pain during or immediately after the exercise, I am quite certain that swelling would not increase further. Important is to restrict the repetitions also initially and increase them gradually, apart from the type of exercise.

You may brace the knee. It helps in the healing and protect the tissues. Brace is better than wrap.

Inflammation and swelling are closely related. There may be internal tissue swelling (called inflammation) with or without external swelling.
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Customer: replied 4 years ago.

I have some further questions.

It seems the knee injury is not too serious as there is very little swelling, but the pain is the main problem whenever I put too much weight on my bad knee. The pain has improved somewhat but slowly and I can now do mild exercises such as leg raises.

I have lost a lot of muscle from staying off it, and for other reasons and I think that is likely the main reason I injured it in the first place. There is a lot more muscle on my good leg around the knee and I can do one legged squats on that knee with no pain.

Right now I am trying to figure out the most effective exercises to build back the muscles around the bad knee, especially the quadriceps.

I used to have very strong quadricep muscles on both legs and could do over 1000 full body squats without any pain, but now even the slightest squat is painful on the bad knee.

Are there exercises that are as effective as squats or lunges for building all of the quadricep muscles?

I have tried leg raises and feel no pain in certain positions. I have been varying the position to see if I can isolate the medialis, intermedialus and femoris, and lateralis. I can figure out a lot of ways to isolate the intermedius/femoris but I am having a lot of trouble figuring out how to isolate the lateralis and medialis.

Do you know of effective exercises to isolate the lateralis quad? The medialis quad? On my good knee these two muscles are much stronger and I assume that is why I feel no pain on that knee.

How can I tell how much or which exercises are actually strengthening the muscles rather than doing too much and aggravating the injury? How do you determine the proper balance?

Thanks for your help.

You are very welcome, Brandon.

Straight leg raising with gradually increasing weight (should start with 2 pounds and increasing one pound every 3-5 days) is as good as squats.

All the four components of quadriceps have some common fibers. Thus they cannot work independently. To further clear this, there are anatomical 4 components but physiologically or functionally these would work in a single unit. So straight leg raise with weight would be the best as it is without weight bearing and still increases the strength of the muscle.

A single guideline that you are not injuring the muscles or muscle fibers is pain or discomfort during or after the exercise. So your body tells you what is optimum for you as this varies hugely in individuals.
Customer: replied 4 years ago.

I have found leg raises the best exercise so far but I do not feel straight leg raises do much for my inner quad around my knee and lower outer quad. Most of the burning I feel is closer to my hips and in the center around the intermedius. On my good knee the inner quad and outer quad closer to my knee are much larger.

Are there certain positions I can sit in when doing the leg raises that better isolate the individual muscles? Such as against the wall, on my side, laying down, direction toes are pointing, etc.

Are there other exercises that might better work out the medialis and the lateralis closer to the knee?


You can do the side raise of lower limbs with being on either side.

The other helpful exercise would be with the weight and raising the leg moving side by side (being you on the back means lying on the back).
Customer: replied 4 years ago.

I am sorry I do not understand the wording of your second suggestion. Can you please re-phrase ?

Sorry for the delay. I had couple of emergency surgery to do. I apologize for your wait.

The exercise is following;

1) Lie down on your back.
2) Tie an appropriate wait.
3) Raise the leg and than also move the leg side by side. So it is extension of the straight leg raising.
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Customer: replied 4 years ago.

I have some more questions about my knee injury.

I am very concerned about aggravating the injury by doing too much, but I am equally concerned about not doing enough and continually re-injuring it because I can't build back enough muscle.

Yesterday I felt less pain and tried a minimal weight bearing exercise by rising up and down slightly from a chair while positioning my rear to minimize the strain on my knees. I could do quite a few repetitions of this without pain and could feel my upper quads being worked significantly. Today my upper quad muscles are sore which is a good thing, however now I feel more knee pain which is not good.

Does this increased knee pain the day after mean that the exercises that were pain free the day before were actually too much?

How can I tell if this increased pain means if the injury has worsened, and it is not just the temporary weakness in my legs from the exercise allowing more strain on my knees temporarily?

You did say that mild pain during exercises is acceptable. How can I determine how much pain is actually aggravating the injury and how much is not?

Hello and welcome Brandon.

Sorry for the delay. I had emergency duty so could not reply you earlier. I apologize for your wait.

The weight bearing exercises are the last exercises to be done, once it is assured that the initial injury has healed completely. The repetitions for weight bearing exercise also increased very slowly as it can aggravate the injury. So the watch word is go very slow. The present pain do indicate that exercises were too much and were beyond the capacity of your muscles. A pain is more indicative of the injury while tiredness or muscles would give you just soreness or mildest discomfort.

The grading of activity / exercises is quite difficult and individuals over work themselves. Thus it is important that you do towards lesser side and start with just 3 repetitions and increase them every 3-4 days. This will not reinjure you and would tell you your optimum. I mentioned, discomfort is allowed, pain is not but again you have to start with the minimum repetitions and have to increase them too slowly. The set of exercises also can be divided in to two sessions (morning and evenings). That too would give you further insight of your capacity.
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Customer: replied 4 years ago.

Because I have no pain at rest, minimal swelling, full range of motion, and only severe pain when I put all my weight on it, I have assumed the injury is not serious and just due to leg muscle weakness and overuse.

I feel the worst pain when putting a lot of weight on the knee and it is all at the front side of the knee. The pain is worst right below the knee cap in the center, but sometimes also right above the knee cap. The pain seems to be closer to the surface. When I twist the knee I feel some pain a little to the left or a little to the right of the knee cap, depending on which direction I twist it.

Does this sound like just an overuse injury from muscle weakness?

Are there signs/symptoms I can look for that would rule out more serious injuries?

Are there tests/manipulations of my knee I can do at home to rule out more serious injuries?

I don't have a lot of money and can't afford an MRI or a physical therapist so I am hoping this is not serious and can be treated with just ice, heat, supplements and strengthening exercises.

You are right that your injury is not serious or severe. You perhaps just need muscle strengthening. With your symptoms, mild tendonitis of quadriceps tendon is likely. Overuse injury is a possibility. There are no tests actually but your observation of minimal swelling, no pain at rest and full range of motion are good enough evidence to rule out a serious injury. I am quite sure that you can treat it yourself but do not overdo and go slow. Too much, too early and too fast (exercises) should be avoided in your case.
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Customer: replied 4 years ago.

I have had severe GI bleeding the past year, hemoglobin dropped to 6. My last 2 blood tests showed hemoglobin above 13 but I don't know presently. Ever since I have been watching my stool very closely for any signs of further bleeding.

When the GI bleeding occurred my stool appeared very dark green appearing black, but not completely black as most people say it should have. It also had a strong distinctive metallic like smell and had clay like consistency.

I have noticed many times that my stool will turn green or sometimes dark enough green to appear black from even 25mg of iron supplements. When this happens the stool will also have the same color, consistency and smell as when it was caused by GI bleeding.

Recently my stool turned green again and had the same smell and consistency. To make sure it was not caused by bleeding I stopped taking iron to see if the color would change back. It has been 4 days off iron and it is still appearing green, clay like, and smells metallic.

I do eat several foods very high in iron such as 4 cups of black beans daily (I have read this amount is more than RDA for iron). I also drink dark grape juice and recently ate black balsamic vinegar for a few days. I also eat a large amount of chicken breast and turkey. My stool is more often not green but when I take more than 15mg of iron supplements it does often turn green, with 25mg iron supplement it turns dark green/black.

Can high levels of iron in the diet alone cause green or dark stool just like with iron supplements?

If so could it be the large amount of black beans that cause the dark green stool and the iron smell?

Could the balsamic vinegar cause darker stool or the metallic smell?

How can I tell if this stool that looks similar to when I had GI bleeding is caused by iron intake rather than bleeding?

Hello and welcome Brandon,

I responded on your another thread too;

Yes, high levels of iron in the diet alone can be responsible for the green or dark stool and iron smell. In your case black beans can cause green color and iron odor. Balsamic vinegar can cause metallic smell of the stool. Unfortunately it is difficult to differentiate the stool color and smell due to supplements and food with GI bleed. The only way one can do is to stop all iron supplements and food with the iron. If the color and smell persists; GI bleed should be suspected.

Please read this authentic resource for the color of the stool;

It is privilege assisting you.
Customer: replied 4 years ago.

Yes I posted it twice because it appeared as if the first time it was not posted to the right thread. Lets use the other thread for followups. Thanks for replying anyway though.

Okay Brandon, I have continued the conversation on the other thread and answered your follow up there.