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14
Zahedan Journal of Research in Medical Sciences
Journal homepage: www.zjrms.ir
Effect of Magnesium Supplementation on Physical Activity of Overweight or
Obese Insomniac Elderly Subjects: A Double-Blind Randomized Clinical Trial
Behnood Abbasi,*1 S. Masood Kimiagar, 2 Minoo Mohammad-Shirazi, 2 Khosro Sadeghniiat, 3 Bahram Rashidkhani, 2 Nastaran Karimi,4
Saeed Doaee 1
1. Department of Nutrition, National Nutrition & Food Technology Research Institute, Faculty of Nutrition and Food Technology, Shahid Beheshti
University of Medical Sciences, Tehran, Iran
2. Department of Clinical Nutrition & Dietetics, National Nutrition and Food Technology Research Institute, Faculty of Nutrition and Food
Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3. Department of Occupational Medicine, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
4. Department of Nutrition, National Nutrition and Food Technology Research Institute, Faculty of Nutrition and Food Technology, Shahid Beheshti
University of Medical Sciences, Tehran, Iran
Article information Abstract
Article history:
Received: 20 Sep 2011
Accepted: 18 Dec 2011
Available online: 30 Oct 2012
ZJRMS 2013; 15(3): 14-19
Background: Strategies for weight reduction often promote lifestyle changes like
encouraging participation in physical activity. Also there is some evidence suggesting an
association between insomnia and physical activity level and probable beneficial effect of
magnesium supplementation on insomnia. The objective of this study was to determine the
effect of magnesium supplementation on physical activity level in insomniac elderly
subjects.
Materials and Methods: A double blind randomized clinical trial was conducted in 46
overweight or obese subjects, randomly allocated into the magnesium or the placebo group
and received 500 mg magnesium or placebo daily for 8 weeks. Questionnaires of insomnia
severity index (ISI), physical activity and sleep-log were completed and serum magnesium
measured at baseline and after the intervention period. Anthropometric confounding
factors, daily intake of magnesium, calcium, potassium, caffeine, calorie form
carbohydrates, fat, protein and total calorie intake, were obtained using 24-hrs recall for 3-
days. Statistical analyses were performed using SPSS-19 software.
Results: No significant differences were observed in assessed variables between the two
groups at the baseline. According to our research magnesium supplementation
significantly increased sleep indices and physical activity level, also resulted in
significantly decrease of total calorie intake in magnesium group. Although serum
magnesium concentration and weight did not show any differences.
Conclusion: In the present study magnesium supplementation resulted in improvement of
sleep indices and physical activity level in elderly subjects. Although according to our
short term intervention no significant beneficial effect was observed on subject`s weight.
Copyright © 2013 Zahedan University of Medical Sciences. All rights reserved.
Keywords:
Magnesium
Physical activity
Obesity
Insomnia
Elderly
*Corresponding author at:
Department of Nutrition,
National Nutrition & Food
Technology Research Institute,
Faculty of Nutrition and Food
Technology, Shahid Beheshti
University of Medical
Sciences, Tehran, Iran.
E-mail:
b.abbasi@nnftri.ac.ir
Introduction
hysical activity level is the first index of the health
in a society, according to World Health
Organization [1]. Obesity has a close relationship
with low physical activity level [2]. The study of health in
Canada in 2004 revealed that the prevalence of obesity in
adults is significantly higher in inactive men (27%)
compared to moderately active (20%) and high active
(17%) individuals. This was also elevated in inactive
(27%) compared to moderately active (21%) and high
active (14%) women [3]. The Copenhagen Heart Study
also showed that people with a higher BMI, has lower
physical activity compared to low BMI individuals and
that obesity development occurs subsequent to reduced
physical activity [4]. Faltun et al. also reported that
moderate and severe physical activity have inverse
correlation with BMI and FMI (Fat Mass Index) indices
[5]. About 70 percent of individuals older than 60 years
are overweight or obese in United States [6] and obesity
through its relationship to cardiovascular diseases is
considered as the first cause of mortality. Thus given the
increasing prevalence of obesity, sedentariness as one of
the reasons or a consequence of obesity is highly
interested. In addition to mentioned issues, by aging of
world population and increment prevalence of chronic
diseases in this group, the importance of physical activity
become clear as a risk-preventive or risk-reducing factor
[7].
The researches performed in Iran revealed that more
than 80% of Iran’s population is physically inactive [8].
Nejati and Ashayeri showed that the physical activity of
60 years and older elders was 57.01% in women and
77.06% in men, and this value reduces the health related
quality of life [9]. Although the importance of active life
is well known but encouraging elderly to physical activity
is very hard and most of them think that they are too old
and fragile for physical activity [10]. Therefore, gradual
P
Effect of magnesium on physical activity of elderly subjects Abbasi B et al.
15
change of life style toward more active life along with
correction of causing factors of inactivity can help to
increase physical activity in this age group.
Along with obesity prevalence, the sleep duration is also
reduced and in various societies reached to 7.2 hours from
8.5 hours per day [11]. Several studies were evaluated the
relationship between these two [12, 13] and found an
inverse relation between self-reporting of sleep hours and
obesity in men, women, and children [14].
Sleep and physical activity may be considered as
separate behaviors which are controlled by different
physiologic mechanisms. But there are growing evidences
regarding to clinical association between sleep and
physical activity [15]. Based on studies, sleep duration is
related to physical activity reduction [16]. In addition,
insomnia leads to reduced physical activity level through
the increase of fatigue and drowsiness during the day [16]
and through its relation to depression-like symptoms and
anxiety [17].
Besides the usual methods of treating sleep disorders,
including medicinal and non-medicinal methods for
which there are weak evidences for their positive impact
and that they produce significant side effects for patient
[18], some studies have evaluated the impact of
magnesium supplementation on insomnia and have
reported positive results [19, 20]. Evaluation of various
studies shows that despite the important physiologic role
of magnesium and its beneficial effects, the dietary intake
of magnesium is inadequate in different societies [21] and
some population groups like elderly and low educated
people have low magnesium intake [22].
The existing statistics also show that insomnia as one of
the most common sleep disorders of elderly has 40 to 50
percent prevalence in elders older than 60 years [23].
There is little information about insomnia prevalence in
Iran. In a study on 224 persons, Arasteh reported no
significant relationship between age, gender, and
insomnia. In this study the prevalence of insomnia in
studied population was reported to be 57.4% [24].
Therefore, regarding to the available information, this
hypothesis is formed as whether the increase of
magnesium intake through supplementation of a safe
amount can lead to physical activity increment, weight
loss and reduction of other chronic diseases in insomniac
individuals through improving the insomnia as a prevalent
disease.
In addition, little numbers of performed studies,
especially in underdeveloped countries and WHO
recommendations for performing dietary clinical trials in
various populations justifies the necessity of this study,
and since elders due to the changes in their physics and
physiology are more prone to insomnia and also due to
their stationary and inactive life style [25].
The purpose of this study is to investigate the impact of
supplementation with 500 mg magnesium for 8 weeks on
physical activity level of elderly subjects with insomnia in
order to correct a changeable factor as the underlying
cause of low activity level.
Materials and Methods
The study was performed in a double-blind randomized
placebo-controlled parallel design. Subjects consisted of
elder men and women older than 60 years with insomnia.
Criteria for inclusion in our RCT included: willing to
cooperate, having insomnia according to ISI questionnaire
(Insomnia Severity Index), having BMI range of 25-34.9,
not having substance or alcohol abuse, dietary intake of
magnesium under 75% RDA (Recommended Dietary
Allowance); serum magnesium level under 0.95 mmol/L,
not receiving loop diuretics, cyclosporine, digoxin,
amphotericin and any hormonal treatment, not having
renal diseases, acute heart failure, restless leg syndrome,
and acute sleep apnea. Reasons for exclusion from the
study were: recent stressful life events (e.g. divorce or
death of a family member) and taking less than 100
tablets of 120.
Regarding to Held et al. study [19], sample size was
estimated to be 23 persons in each group. Insomnia
severity index test was taken from the elders who referred
to Culture Houses of Tehran’s 1, 10, and 14 regions with
insomnia complaint (as self-report). When their insomnia
has been confirmed by ISI questionnaire (clinically
moderate or severe), and their sleep time was registered in
Sleep Log questionnaire for 14 days, prior to begin
supplementation (Run-in phase). Then for those who were
consistent with inclusion criteria and lacked the exclusion
criteria of the study, the benefits, the aim, and duration of
the study, and mode of intervention were described in a
briefing. A written consent form was then obtained from
participants. Three persons (2 women and 1 man) were
excluded from the study regarding to the exclusion
criteria. General information, insomnia severity index,
Sleep Log, and physical activity questionnaires were
completed and serum magnesium level was measured by
atomic absorption method at the beginning and the end of
the study. At baseline and end of the intervention period
confounding factors including anthropometric
measurements, weight, BMI, total energy intake, dietary
magnesium, potassium, calcium and caffeine were
determined.
Anthropometric measurements were done by trained
colleagues, so according to WHO standards, the light
cloth worn patients were weighted and their height were
measured without shoes with a 0.5 cm accuracy wall
meter. Using the weight (in kilograms) divided by height
(in meters) square formula, BMI was calculated and the
obtained information was recorded in general information
questionnaire of patients. Then based on the unique and
randomly assigned codes of participants, magnesium and
placebo containing packages were distributed among
them. Patients in magnesium supplementation group
received 500 mg elemental magnesium tablets for 8
weeks while the placebo group received starch containing
placebo during the study. Since the study was double-
blind, in order to uniform the research executive from
packages content, a person outside the study divided the
Zahedan J Res Med Sci 2013 Mar; 15(3): 14-19
16
tablets into groups A and B and put them in identical
packages.
To prevent undesired gastrointestinal effects, it was
suggested to consume the pills along with the main meals
(lunch and dinner). During the study any information
about weight loss was not given to participants and they
continued their normal life except the intake of 500 mg
magnesium or the placebo. The dietary information was
obtained from 24 hours recall questionnaire (2 usual days
and 1 day off) and analyzed with Nutritionist 4 software
(N4) and daily total energy, magnesium, calcium,
potassium, and caffeine intake of each person was
determined at the beginning of the study. Kolmogorov-
Smirnov test was used to analyze the distribution mode of
the variables. The studied variables were compared at the
beginning and the end of the study with paired t-test and
the studied variables between magnesium
supplementation and placebo groups were compared with
independent samples t-test. The variables were analyzed
by SPSS-19 software and p-value calculated as two-tailed.
The p< 0.05 is considered statistically significant.
The subjects were voluntarily entered in the study with
full knowledge of design, methods, and materials. They
also signed a written consent form and were free to be
excluded whenever they had no desire to continue the
study.
According to our review, no side effects were seen in
consumers of magnesium supplement or starch containing
placebo at prescribed dose. However, high dose
magnesium-induced diarrhea has been reported in some
studies. At the end of the study, as expected by the
researchers, any complaints or complications were not
reported. The study has been approved by the Medical
Ethics Committee of Shahid Beheshti University of
Medical Sciences and has been registered in the center of
clinical trials registration of Iran.
Results
Total of 46 persons participating in the study, 2 persons
due to not regular consuming of supplement or placebo
and one person due to not participating in second turn
blood sampling, were excluded from the study. At the
end, 43 persons (21 men and 22 women) completed the
study. The age, weight, height, body mass index and
physical activity level means and standard deviations of
contributors were 65±4.6 years, 72.1±9.7 kg, 29.2±3.7
kg/m2 and 2.8±0.7 MET h/day respectively.
The dietary intakes of the study participants at the
baseline and end of the study are shown in Table 1.
During the study, the dietary intake of individuals in none
of investigated micronutrients and caffeine intake showed
no significant statistical difference. As seen in Table 2,
the results of this study show that sleep time (ST)
(p=0.002) and sleep efficiency (SE) (p=0.03) increased
and Sleep onset latency (SOL) (p=0.02) decreased, both
significantly. However, total sleep time (TST) (p=0.37)
and early morning awakening (EMA) (p=0.08) did not
shown a significant difference.
As seen in table 3 total energy intake (p=0.02)
decreased and physical activity level (p=0.02) increased
both significantly in magnesium group compared to
placebo group. Despite favorable increase of serum
magnesium concentration (p=0.06) during this study, the
related changes in its level were not significant. As
researchers expected, volunteers participants in the study
did not report any adverse effects and the results of this
study showed that daily consumption of supplements as
500 mg magnesium oxide in two doses of 250 mg along
with the meal does not lead to any complications in the
elders.
Discussion
In the present study, serum magnesium level in
supplement group tended to augment (p=0.06), however a
significant difference between two groups was not seen at
the end of the study. The obtained results from our study
are consistent with the study of Hoogerbrugge et al. who
investigated the effect of supplementation with 1 gram
magnesium oxide for 6 weeks on Lipoprotein (a) level in
hypercholesterolemic patients and did not observe a
significant difference in serum magnesium increment
[26].
Held et al. also, in a study which dealt with magnesium
supplementation in 12 healthy persons could not
recognize a significant difference between two groups,
despite detection of serum magnesium tendency toward
increase in the supplementation group [19].
Guerrero and Rodriguez in their study to investigate the
effect of magnesium supplement in lowering blood
pressure of hypertensive diabetic patients, reported that
during 4 month of supplementation with 450 mg/day
elemental magnesium, serum magnesium concentration in
the intervention group compared to placebo group,
increased gradually and reached a significant level at the
third month [27].
Table 1. Means and standard deviations of dietary confounding factors in magnesium supplementation and placebo groups at baseline
Variable Magnesium Supplementation Placebo p-Value
Dietary magnesium intake (mg/day) 190±55 198±54 0.970
Dietary calcium intake (mg/day) 829±317 795±365 0.743
Dietary potassium intake (mg/day) 3006±897 2996±772 0.970
Dietary caffeine intake (mg/day) 77±43 69±29 0.475
Effect of magnesium on physical activity of elderly subjects Abbasi B et al.
17
Table 2. Comparison of sleep indices in magnesium supplementation and placebo groups before and after intervention
Magnesium Supplementation (n=21) Placebo (n=22)
Variable Before intervention After
intervention
Difference
(CI=95%) Before intervention After
intervention
Difference
(CI=95%)
Total sleep time (hrs.) 7.8±1.1 7.9±0.6 0.1±0.7 7.6±0.9 7.6±0.8 -0.03±0.3
Sleep time (hrs.) 5.1±0.8 5.7±0.9 0.6±0.7٭ 5.0±0.5 5.0±0.6 -0.02±0.3
Sleep onset latency (hrs.) 1.3±0.2 1.1±0.4 -0.2±0.4٭ 1.4±0.2 1.4±0.2 0.04±0.1
Early morning awakening (hrs.) 1.04±0.02 1.01±0.05 -0.03±0.05 1.03±0.02 1.03±0.02 -0.01±0.01
Sleep efficiency (hrs.) 0.67±0.07 0.73±0.1 0.06±0.1٭ 0.66±0.04 0.66±0.07 0.00±0.05
p<0.05*
Regarding to this study and increment trend of serum
magnesium in our study, this is possible that the duration
of our study was inadequate to observe a significant
difference in serum magnesium alterations. This
resistance to change of serum magnesium levels could
also be attributed to its important role as a cofactor and
the need to precisely regulate its concentration.
The results of our study show that sleep time (p=0.002)
and sleep efficiency (p=0.03) increased and Sleep onset
latency (p=0.02) decreased, both significantly. Results of
the present study about the role of magnesium in sleep
regulation are consistent with Dralle and Bodeker study
which showed that there is an association between
magnesium supplementation and REM (Rapid eye
movement), muscle tone, and gross body movements in
infants. Results of Dralle and Bodeker also suggested that
there is a relationship between serum magnesium level
and active sleep, and between serum magnesium level and
quiet sleep, and magnesium supplementation increased
the quiet sleep and decreased the active sleep [28]. In a
study conducted by Held et al. to analyze magnesium
supplementation effects on sleep EEG , plasma ACTH
(Adrenocorticotropic hormone), cortisol, AVP (Arginine
vasopressin), renin, angiotensin II, and aldosterone in
elderly, he showed that the most important Mg2+
supplementation effect in healthy elderly subjects was
SWS (Short Wave Sleep) increment [19]. Beside NMDA
(N-methyl-D-aspartate) antagonistic properties, Mg2+ also
has endocrine effects such as an ATII-antagonistic action
[29] and a dampening effect on HPA-system
(Hypothalamic-Pituitary-Adrenal Axis) activity [30].
Also, the results of our study are consistent with
Rondanelli et al. study which was done to investigate the
effects of combined melatonin, magnesium, and zinc
supplementation, which showed that the supplementation
resulted in total score improvement of Pittsburg
questionnaire compared to placebo, and suggested that
treatment has beneficial effects on capability of
recovering body activities through sleep [20].
Physical activity level in magnesium supplement group
was increased significantly compared to placebo group.
These results were consistent with study hypothesis that
magnesium supplementation may be able to increase
physical activity levels of volunteers participating in the
intervention through correcting their insomnia problem.
The obtained results were consistent with Chasens and
Yang study which suggested that insomnia symptoms
were associated with reduction of physical activity level
and although the insomnia is a state of brain arousal, the
end result of insomnia is increment of fatigue and
sedentariness and finally insomnia can lead to reduced
levels of physical activity through increment of fatigue
and drowsiness during the day [16]. In addition, the
results of this study were consistent with Stamatakis and
Brownson study which suggested that sleeping time
reduction was associated with high-risk behaviors related
to weight increase such as physical activity reduction and
fruit and vegetable intake reduction [31].
In the present study, total calorie intake and energy
intake from carbohydrates show a significant decrease in
magnesium group, while in placebo group a significant
difference was not observed. Regarding to the results of
Nedeltchev et al. study conducted on 11 healthy women
and men, sleep deprivation can alter the composition and
distribution of human dietary intake and in a favorable
environment for obesity, inadequate sleep can facilitate
energy intake from snacks further than main dietary meals
[32]. The results of Shi et al. study, also confirmed the
relationship between sleep time and carbohydrate intake
[33]. Also, the results of Weiss et al. study performed on
240 adolescents 17.7±0.4 years old showed that sleeping
time reduction led to 2.2% calorie intake increment from
fat and 3% calorie intake reduction from carbohydrate.
These minor alterations can increase the risk of obesity
through the accumulated effect of modified energy intake
balance over time [34].
In our study the energy intake from fat showed a
significant reduction in magnesium supplementation
group, while in placebo group a significant difference was
not observed. In addition there was no difference in
calorie intake from protein in the studied groups. This was
consistent with the results of Shi et al. study conducted on
2828 Chinese men and women which showed a
significant relationship between sleep duration and fat and
carbohydrate intake. In this study the persons with daily
sleep lower than 7 hours had more energy intake from fat
in comparison with whom slept 7-9 hours a day [33]. In
this relation, several mechanisms can be involved such as,
reduced glucose tolerance, reduced sensitivity to insulin,
increased sympatho-vagal regulation, increased cortisol
level, increased ghrelin level, and reduced leptin level,
upregulation of orexin neurons activity, alteration of
orexin neurons activity, and appetite regulating hormones
which may increase feeling hungry and appetite [35]. In
other human studies, reduction of sleeping time was
associated with fat intake increment [33] and energy
intake increment from snacks [32]. There is no doubt that
a strong relationship exists between sleep and obesity, but
its mechanism and direction are not known and needs to
Zahedan J Res Med Sci 2013 Mar; 15(3): 14-19
18
be further investigated (longitudinal, interventional, or
both).
In general, the results of this study show a favorable
significant effect of magnesium supplementation on sleep
time, sleep efficiency and physical activity level as well
as insomnia severity index reduction, sleep onset latency,
total calorie intake, calorie intake from fat and calorie
intake from carbohydrate in insomniac elderly subjects.
However, observing the increasing of serum magnesium
level and weight reduction did not cause a significant
difference in these variables; this can be the result of the
short time of the study.One potential weakness of this
study is its short duration which make difficult to opine
about those variables which have a slow response to the
treatment. Therefore we suggest to perform the future
studies of this field in a longer time and to measure the
possible effects of intervention on weight reduction in
insomniac patients. Also, monitoring the physical activity
level using actigraphy can help to increase the accuracy of
next studies.
Acknowledgements
The present article is the result of research conducted by
Prof. Masud Kimiagar and Behnood Abbasi. The study
protocol was approved by Shahid Beheshty University of
medical sciences (reg. no. 041400). All people who
assisted us in this study, particularly the National
Nutrition and Food Technology Research Institute for its
financial supports, Prof. Ahmad Zand Moghadam and Dr.
Majid Karandish for their scientific supports are
appreciated.
Authors’ Contributions
All authors had equal role in design, work, statistical
analysis and manuscript writing.
Conflict of Interest
The authors declare no conflict of interest.
Funding/Support
Shahid Beheshti University of Medical Sciences.
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Please cite this article as: Abbasi B, Kimiagar S.M, Mohammad-Shirazi M, Sadeghniiat K, Rashidkhani B, Karimi N, Doaee S. Effect of
magnesium supplementation on physical activity of overweight or obese insomniac elderly subjects: A double-blind randomized clinical
trial. Zahedan J Res Med Sci (ZJRMS) 2013; 15(3): 14-19.
