Introduction

"My magnesium levels are normal."

Translation: Your doctor may have ordered the wrong test, and you might still be deficient.

The problem: Many doctors order serum magnesium, which only measures about 1% of your body's magnesium and can be "normal" while your tissues are depleted.

The reality:

• Serum magnesium: Measures blood magnesium (approximately 1% of total body stores)

• Can be "normal" (1.7-2.2 mg/dL) while intracellular levels are low

• May only drop when deficiency is severe and long-standing

What you may need instead: RBC Magnesium (red blood cell magnesium)

• Measures intracellular magnesium (reflects tissue stores)

• May show deficiency weeks to months earlier than serum

• Optimal range often cited: 5.5-6.5 mg/dL (not just the conventional "normal" 4.2-6.8)

Expert perspectives:

• Peter Attia, MD: Targets 5.5-6.0 mg/dL (high-normal)

• Bryan Johnson (Blueprint): Targets 6.0-6.5 mg/dL (upper optimal)

• Andrew Huberman, PhD: Recommends 5.5-6.0 mg/dL ("high-normal, not just normal")

In this guide, you'll learn:

• Why serum magnesium may be less reliable (and when it's useful)

• How to interpret RBC magnesium (optimal vs. conventional ranges)

• Related biomarkers to test (calcium, vitamin D, potassium, PTH, insulin)

• How to order the right tests (and what to do if your doctor is unsure)

• Tracking protocols (baseline, follow-up, maintenance)

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Serum Magnesium (Unreliable for Most People)

What It Measures:

• Magnesium in blood plasma/serum

• Represents only 1% of total body magnesium

• 99% of magnesium is intracellular (bones, muscles, organs)

Reference Range:

• Conventional "normal": 1.7-2.5 mg/dL (0.7-1.1 mmol/L)

• Most labs use 1.7-2.2 mg/dL

The Problem:

• Body tightly regulates serum levels (pulls from bones/tissues to maintain blood levels)

• Can be "normal" while tissues are depleted

• May only drop below normal when deficiency is severe and prolonged (Stage 3)

Example:

• Stage 1-2 deficiency (symptomatic): Serum 1.9 mg/dL ("normal")

• RBC magnesium: 4.2 mg/dL (may indicate deficiency)

• Tissues may be depleted for months, but serum still "normal"

Here's the reality: blood tests don't always tell the whole story about tissue-level nutrient status.

When Serum Magnesium IS Useful:

Ruling out severe, acute deficiency (<1.5 mg/dL = emergency)
Monitoring renal failure (risk of hypermagnesemia)
Acute medical settings (ICU, cardiac emergencies)

When Serum Magnesium is NOT Useful:

Detecting chronic, subclinical deficiency (most people)
Monitoring supplement effectiveness
Optimizing for longevity/performance

RBC Magnesium (Gold Standard for Most People)

What It Measures:

• Magnesium inside red blood cells (intracellular)

• Reflects tissue magnesium stores

• More sensitive-shows deficiency weeks to months earlier than serum

Conventional Reference Range:

• Most labs: 4.2-6.8 mg/dL

• Often reported as 42-68 mg/L or 1.72-2.79 mmol/L

The Problem with Conventional Ranges:

• Too wide (4.2-6.8 is a huge range)

• Based on "average" population (which is 75% magnesium insufficient)

• "Normal" includes many deficient people

Functional Optimal Range:

• 5.5-6.5 mg/dL (longevity-focused practitioners target this)

• This is where symptoms resolve and health outcomes optimize

Interpretation:

Expert Targets:

• Peter Attia: 5.5-6.0 mg/dL ("high-normal")

• Bryan Johnson: 6.0-6.5 mg/dL (upper optimal for longevity)

• Andrew Huberman: 5.5-6.0 mg/dL ("not just normal, high-normal")

1. Vitamin D (25-Hydroxyvitamin D)

Why Test with Magnesium:

• Magnesium required to activate vitamin D (every step of D metabolism)

• Vitamin D enhances magnesium absorption 30-40%

• 50% of people supplementing D have low magnesium (explains non-responders)

Optimal Range:

• 40-60 ng/mL (100-150 nmol/L)

• Not the conventional "normal" >30 ng/mL (insufficient)

Interpretation with Magnesium:

Peter Attia's Protocol: Never gives D without K2 and magnesium-"they're inseparable."

2. Serum Calcium (Total and Ionized)

Why Test:

• Magnesium regulates calcium (keeps it in bones, out of soft tissues/arteries)

• Low magnesium can cause:

  • Hypocalcemia (low calcium): Mg required for PTH secretion

  • Hypercalcemia (high calcium): Mg deficiency impairs regulation

Optimal Ranges:

• Total Calcium: 9.0-10.5 mg/dL

• Ionized Calcium: 4.5-5.3 mg/dL (more accurate, but less commonly ordered)

Calcium:Magnesium Ratio:

• Optimal: 2:1 to 1:1 (calcium to magnesium in diet/supplements)

• Problem: Most people get 5:1 or higher (too much calcium, not enough magnesium)

Interpretation:

3. Parathyroid Hormone (PTH)

Why Test:

• Magnesium required for PTH secretion

• Low Mg impairs PTH -> secondary hypocalcemia

• Also: chronic low Mg may cause mild PTH elevation (secondary hyperparathyroidism)

Optimal Range:

• 15-50 pg/mL

• Not the conventional "normal" up to 65-70 pg/mL

Interpretation:

4. Potassium (Serum)

Why Test:

• Magnesium required for potassium retention in cells

• Low magnesium causes refractory hypokalemia (low potassium that won't correct with potassium supplementation alone)

Optimal Range:

• 4.0-5.0 mEq/L

• Not the conventional "normal" 3.5-5.5 (low end is suboptimal)

Interpretation:

Clinical Pearl: If potassium is low and won't correct with supplementation, always check (and correct) magnesium.

5. Fasting Insulin & HbA1c (Glucose Metabolism)

Why Test:

• Magnesium critical for insulin sensitivity

• Magnesium deficiency worsens insulin resistance -> type 2 diabetes

• 80% of type 2 diabetics are magnesium deficient

Optimal Ranges:

• Fasting Insulin: <5 uIU/mL (longevity target)

• HbA1c: <5.3% (optimal metabolic health)

• Conventional "normal" is higher (insulin <25, HbA1c <5.7%) but not optimal

Interpretation:

Research: Magnesium supplementation (400-600 mg daily) improves insulin sensitivity 30-40% in deficient individuals.

6. hsCRP (High-Sensitivity C-Reactive Protein)

Why Test:

• Inflammation marker

• Magnesium deficiency increases inflammation

• Low magnesium associated with elevated hsCRP

Optimal Range:

• <1.0 mg/L (low cardiovascular risk)

• 1.0-3.0 = moderate risk

• >3.0 = high risk

Interpretation:

• Elevated hsCRP + Low Mg -> Mg correction reduces inflammation 20-40%

Photo from Unsplash

Option 1 - Request from Your Doctor

What to Say:
"I'd like to check my intracellular magnesium status with an RBC Magnesium test, not serum magnesium. Serum only shows 1% of body stores and can miss chronic deficiency."

If your doctor resists:

• Share this guide or research (Costello 2016 study below)

• Explain symptoms (insomnia, cramps, anxiety, fatigue)

• Mention that serum is unreliable for screening

Lab Codes:

• RBC Magnesium: CPT code 83735

• Request: "RBC Magnesium" or "Erythrocyte Magnesium" or "Intracellular Magnesium"

Option 2 - Order Direct-to-Consumer

If your doctor won't order it (or you want to test proactively):

Reputable Direct-to-Consumer Labs:

• Mito Health (comprehensive panels including RBC Mg) [CTA link]

• Life Extension (LifeExtension.com-RBC Magnesium ~$50)

• Ulta Lab Tests (UltaLabTests.com)

• Request A Test (RequestATest.com)

Cost: $50-150 for RBC Magnesium alone
Comprehensive Micronutrient Panels: $300-600 (include RBC Mg, vitamins, minerals)

Option 3 - Comprehensive Micronutrient Testing

Best for Optimization:

• Tests RBC Magnesium + other intracellular nutrients

• Identifies multiple deficiencies simultaneously

Panels Include:

• RBC Magnesium, Zinc, Selenium

• Vitamin D, B12, Folate

• CoQ10, Omega-3 Index

• And more

Companies:

• SpectraCell (Micronutrient Testing)

• Genova Diagnostics (NutrEval)

• Mito Health (Longevity panels)

Cost: $300-600
Worth it: If optimizing multiple nutrients simultaneously

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Phase 1 - Baseline Testing (Before Starting Supplementation)

Essential:

• RBC Magnesium

• 25(OH)D (vitamin D)

Recommended:

• Serum Calcium

• Parathyroid Hormone (PTH)

• Fasting Insulin + HbA1c

• hsCRP

• Potassium

Interpret: See tables above
Document: Your starting point (essential to measure progress)

Phase 2 - Start Supplementation Protocol

Based on RBC Magnesium Results:

Always include cofactors:

• Vitamin D3: 4,000-5,000 IU (if D is also low)

• Vitamin K2-MK7: 100-200 mcg

• Vitamin B6 (P5P): 50-100 mg

Phase 3 - Follow-Up Testing (8-12 Weeks)

Retest:

• RBC Magnesium

• 25(OH)D (if supplementing D)

• Others if initially abnormal

Expected Improvements:

If NOT improving as expected:

• Absorption issue -> try liposomal magnesium

• Ongoing losses -> address stress, medications, alcohol

• Compliance -> simplify protocol

• Increase dose (if well-tolerated)

Phase 4 - Maintenance (Once Optimal)

Once RBC Mg 5.5-6.5 mg/dL:

Maintenance Dose:

• 200-400 mg daily (depends on lifestyle)

• Athletes: 400-600 mg (higher losses)

• Stress/medications: 300-500 mg

• General health: 200-300 mg

Retest Frequency:

• Every 6-12 months (ensure maintaining)

• After major life changes (new medications, pregnancy, increased training)

• If symptoms return -> retest sooner

Magnesium Loading Test (Optional, Advanced)

What It Is:

• Give large dose magnesium (oral or IV)

• Measure 24-hour urinary excretion

• If <80% excreted -> body retaining (indicates deficiency)

Procedure:

• Collect baseline 24-hour urine

• Give magnesium load (oral 30 mg/kg or IV)

• Collect 24-hour urine after load

• Calculate retention

Interpretation:

• <80% excreted = deficient (retaining magnesium)

• 
  
  
  
  

80% excreted = adequate (excreting excess)

Pros:

• Very accurate for total body magnesium status

• "Gold standard" in research

Cons:

• Cumbersome (24-hour urine collection)

• Not widely available clinically

• Expensive

• RBC Magnesium is sufficient for most people

Case 1 - "Normal" Serum, Deficient RBC

Patient: 42-year-old female, chronic insomnia, muscle cramps

Labs:

• Serum Magnesium: 1.9 mg/dL ("normal" 1.7-2.2)

• RBC Magnesium: 4.3 mg/dL (deficient, optimal >5.5)

• 25(OH)D: 24 ng/mL (low)

Doctor's initial response: "Your magnesium is normal, nothing to worry about."

Reality: Intracellular deficiency despite "normal" serum

Protocol:

• Magnesium glycinate 400 mg daily (split)

• Vitamin D3 5,000 IU

• K2 200 mcg

12-Week Follow-Up:

• RBC Magnesium: 5.6 mg/dL (optimal)

• 25(OH)D: 48 ng/mL (optimal)

• Symptoms: Insomnia resolved, cramps gone

Lesson: Serum magnesium missed the deficiency. RBC test was essential.

Case 2 - Refractory Hypokalemia (Low Potassium Won't Correct)

Patient: 55-year-old male on diuretic, muscle weakness, palpitations

Labs:

• Potassium: 3.2 mEq/L (low, optimal >4.0)

• Prescribed potassium supplements -> K still low after 4 weeks

• Serum Magnesium: 1.8 mg/dL ("normal")

• RBC Magnesium: Not initially checked

Requested RBC Magnesium:

• RBC Mg: 4.1 mg/dL (deficient)

Diagnosis: Magnesium deficiency causing refractory hypokalemia

Protocol:

• Magnesium glycinate 500 mg daily

• Continue potassium supplement

4 Weeks Later:

• RBC Magnesium: 4.9 mg/dL (improved)

• Potassium: 4.2 mEq/L (normalized)

• Symptoms: Resolved

Lesson: Potassium won't correct until magnesium is adequate. Always check (and correct) Mg first.

Case 3 - Optimizing for Longevity

Patient: Bryan Johnson approach-35-year-old male, no symptoms, wants optimal biomarkers

Baseline Labs:

• RBC Magnesium: 5.2 mg/dL ("normal" but not optimal)

• 25(OH)D: 38 ng/mL (adequate but not optimal)

• Fasting Insulin: 6.8 uIU/mL (good, but target <5)

• hsCRP: 1.2 mg/L (moderate risk, target <1.0)

Protocol:

• Magnesium glycinate 400 mg daily

• Vitamin D3 5,000 IU

• K2-MK7 200 mcg

• Omega-3 2-3g EPA+DHA

12-Week Follow-Up:

• RBC Magnesium: 6.1 mg/dL (optimal)

• 25(OH)D: 56 ng/mL (optimal)

• Fasting Insulin: 4.2 uIU/mL (optimal)

• hsCRP: 0.6 mg/L (optimal)

Lesson: Moving from "normal" to "optimal" improves metabolic and inflammatory markers.

Key Takeaways

• Serum magnesium is unreliable - Measures only 1% of body stores; can be "normal" while tissues are severely depleted

• RBC Magnesium is the gold standard - Shows intracellular levels and detects deficiency weeks to months earlier than serum

• Optimal RBC range is 5.5-6.5 mg/dL - Not the conventional "normal" 4.2-6.8 mg/dL that includes deficient people

• Expert practitioners target 5.5-6.0+ - Peter Attia, Bryan Johnson, and Andrew Huberman all recommend high-normal ranges

• Test related biomarkers together - Vitamin D (40-60 ng/mL), calcium, PTH, potassium, insulin, and hsCRP provide complete picture

• Refractory hypokalemia requires magnesium first - Low potassium that won't correct often indicates magnesium deficiency

• Retest at 8-12 weeks - Expect RBC Mg to increase 0.5-1.0 mg/dL with 400-600 mg daily supplementation

• Maintenance testing every 6-12 months - Once optimal, monitor annually or when symptoms return

• Order direct if needed - Life Extension, Ulta Lab Tests, or comprehensive panels cost $50-600 depending on scope

Medical Disclaimer

This article is for educational and informational purposes only and does not constitute medical advice. The information provided should not be used for diagnosing or treating a health condition. Always consult with your doctor or qualified healthcare provider before starting any new supplement protocol, making changes to your diet, or if you have questions about a medical condition.

Individual results may vary. The dosages and protocols discussed are evidence-based but should be personalized under medical supervision, especially if you have existing health conditions or take medications.

Related Content

• Magnesium Deficiency Symptoms

• Raising Magnesium Levels

• Magnesium Dosage By Age

References

1. Costello RB, Elin RJ, Rosanoff A, et al. Perspective: The Case for an Evidence-Based Reference Interval for Serum Magnesium: The Time Has Come. Adv Nutr. 2016;7(6):977-993. PMID: 28140318 | PMC5105035

2. Elin RJ. Assessment of magnesium status for diagnosis and therapy. Magnes Res. 2010;23(4):S194-8. PMID: 20736141

3. DiNicolantonio JJ, O'Keefe JH, Wilson W. Subclinical magnesium deficiency: a principal driver of cardiovascular disease and a public health crisis. Open Heart. 2018;5(1):e000668. PMID: 29387426 | PMC5786912

4. Workinger JL, Doyle RP, Bortz J. Challenges in the Diagnosis of Magnesium Status. Nutrients. 2018;10(9):1202. PMID: 30200431 | PMC6163803

5. Rosanoff A, Weaver CM, Rude RK. Suboptimal magnesium status in the United States: are the health consequences underestimated? Nutr Rev. 2012;70(3):153-64. PMID: 22364157