What does the research show about the benefits of creatine supplements?
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This is a CBC Podcast. Hi, I'm Dr. Brian Goldman. Welcome to The Dose. Creatine is a naturally occurring substance found in the human body that helps supply energy to muscles and brains.

It is also available as a supplement and has long been used by athletes and some weekend warriors to build strong muscles or at least to make muscles work better. More recently, there's some research, in fact, there's growing research suggesting it can improve cognition. So this week we are asking...

What does the research show about the benefits of creatine supplements? Hi, Darren. Welcome to The Dose. Hi, Brian. How are you? I am fine. I got a question for you. Do you take creatine? I do. I've been taking creatine daily for the last at least two decades. I only use creatine monohydrate. Well, well, you're the expert. So we're going to want to know why that and what

the benefits are. But before we begin, can you give us a hi, my name is, tell us what you do and where you do it. Yeah, my name is Darren Kandel. I'm a professor at the University of Regina in the Faculty of Kinesiology and Health Studies. And I'm also the director of the Aging Muscle and Bone Health Laboratory at our university as well. All of those qualifications are perfect for the discussion we're about to have. Okay, where is creatine usually found in the human body and what is its purpose?

Yeah, actually, there's only two places. We produce it in the liver, and we actually also produce it in the brain. And we only produce about maybe one to three grams. Some of that depends on your diet. You can get creatine also through primarily animal-based proteins such as red meat and seafood, or most people are familiar with creatine supplements. It's there basically to help maintain the energy currency of our cell called adenosine triphosphate.

So when we're performing exercise or activities of daily living, we use ATP to allow that and fossil creatine and creatine help come to the aid of maintaining those levels. Now, so we know where we synthesize creatine. You mentioned foods, specifically which foods have the highest creatine content?

Yeah, the fattier the fish or the colder water environments such as mackerel, herring and sardines would have the highest concentration. For red meat perspective, beef would be leading the way there. There's a little bit in poultry, chicken and turkey, but only trace amounts found in dairy. So for those that are eating red meat or seafood maybe once or a few times a week, you're getting a little bit of creatine there.

But that begs the question, what about the vegans, vegetarians and those on a plant-based diet? That was on my list. So what about vegans? Yeah, unfortunately, they're not getting any habitual dietary creatine. So they're relying on what's being made in their body. And they're only probably producing about one to two grams at most.

And then we also excrete the exact same amount in something called creatinine. People would be familiar when they go to their doctor and they see that on their blood requisition form. So there's usually an equal balance, what we're naturally either synthesizing or eating and comparing that to what we're excreting. Let's turn now to creatine as a supplement. You've already said you consume creatine monohydrate. That's the best form of it. And if it is, why?

Yeah, that one's the safest and most effective. There's over a thousand peer referee journal articles, 99.9% use creatine monohydrate. And the reason mainly is that monohydrate meaning water, there's a water molecule simply linked to creatine monohydrate.

Once you consume it, that water molecule dissolves and that molecule called creatine is identical to what's being naturally produced in the liver or brain. And that's probably why the safety profile of creatine is exceptional. There are other supplemental forms. I've heard of creatine hydrochloride. How effective

None of these will even come close to monohydrate. I think there's a lot of marketing. Maybe creatine monohydrate was too good to be true. It was discovered in 1832. And I think in today's society with social media or pressures, we're always trying to come up with something better and fancier. And when monohydrate's bioavailability or even absorption is around 100%, it's very hard to beat that. So I would only recommend monohydrate.

Let's start talking about the research. What does the research show about the muscular benefits of creatine supplementation, so creatine monohydrate? Creatine is probably one of the most effective supplements to consume from a muscle performance perspective. It's been shown in all ages across the lifespan to improve lean mass, muscle size.

Probably more importantly, muscle performance. And I highlight muscle strength there because as we get older, the reduction in muscle strength primarily is one of the main reasons that we can't live longer free of disease. So when creatine is combined with exercise primarily, it really seems to improve muscle performance.

Thirdly, there you also get improvement in functionality, such as an improvement of sit to stand. So think of an older adult getting out of bed or off the toilet or something that's very functional. But at a younger age, it definitely improves agility, balance and coordination. So it seems to really have the most effects from a muscle performance perspective.

And when you mention, when you talk about muscles, fast twitch fibers, I know it does that. Does it also help slow twitch fibers? Yeah, it helps both. But the biggest concentration is found in our large type two fibers or fast twitch. And that's where we seem to have the greatest body of evidence. And it kind of makes sense if these muscle fibers are a bit larger and used during explosive anaerobic activities such as sprinting or weightlifting. That's really where creatine's main body of research seems to be the most effective.

primarily in young males, but it also has been shown now in young females from an accumulating perspective. As a real world example, if you're going to go from a sit to stand position, you're using fast twitch fibers, aren't you?

You are. And you're also using the lower limbs as well as the upper limbs. And that's for everybody across the lifespan. And these are really important to remember as we get older, you know, taking the stairs, things like those, they activate these larger type two fibers, which are crucial for longevity. Can you quantify the muscle improvements? How much stronger, how much better do our muscles work?

On average, if you just perform weight training and you do it for maybe four to six weeks, you probably get about an 8% to 10% improvement in muscle performance. Creatine, we think, almost gives you an extra 10%. So that could be really important for certain populations, primarily aging and athletes. So from a muscle performance, you almost double it. From a lean mass perspective, you increase by about 1.4 kilograms.

or about three pounds, and half of that we think is muscle. So, you know, that's really important from many populations, clinical, healthy, and of course, aging. Is it just muscle power and resistance training that benefit from creatine supplementation?

Well, no, there's a whole explosion on the health aspects of creatine with and without exercise. But we really try to promote exercise. It really seems to stimulate the vast beneficial effects of creatine, primarily from a muscle and bone health perspective. From the brain, it seems like you can still get benefits without exercise, but those seem to be the two avenues. Exercise and creatine really like to work together to get the plethora of benefits.

So you've talked about muscles. What about the skeletal benefits of creatine supplements? Yes, specifically from a bone perspective, there are research suggesting that creatine can decrease bone mineral density loss.

It also has some evidence to suggest it decreases bone resorption. When you put those two together, we've concluded that creatine has some anti-catabolic effects to the skeleton where it may help reserve bone. We do not see any increases in bone mineral density. So obviously it's not going to be a cure for osteoporosis, but it could be an intervention to help maintain the skeleton as we get older. Have the studies that look at exercise performance been short-term studies like four weeks? My question is,

You know, okay, there's a benefit of four weeks, but what about at six months or a year? Yeah, that's an excellent question. So you're right. The vast majority have been short term, but we've actually done the longest trial ever to date. It was two years consecutively in an older adult population taking a high dose of creatine and it was shown to improve lean tissue mass and muscle strength as well. So the longest training study has been two years, but you're right. The vast majority are well under six months.

And so there still needs to be a lot more research looking at a year, two years, or even longer. Do you get continuous benefit or does it plateau? There's no evidence to suggest we need to cycle it. You can take it continuously, but there's also no evidence to suggest that the benefit's

plateau, except obviously all humans have a physiological limit. So, you know, once you get that rapid increase in strength or muscle, it's highly likely you would plateau after, you know, six months, seven months. Maybe you need to change up the program or the different dosing. But actually, that's a good point. No study's ever done that.

Before we get to cognition, there are other potential non-muscular benefits. I'm thinking about blood sugar, lipid metabolism. What do we know about that? There's actually been great research out of Brazil showing specifically for type 2 diabetes that creatine can sort of decrease blood glucose levels by allowing more glucose to get into your muscle primarily. It stimulates a protein called GLUT4. So there's a lot of hope.

primarily as an adjunct to exercise or improving blood glucose levels. There's also some preliminary research suggesting it can decrease blood triglycerides and cholesterol. The mechanisms are still unclear there, but we have shown in a couple meta-analysis that when you combine creatine and weight training, you get a reduction in fat mass. It's very small, but it is a reduction. So we're hoping that could have applications for longevity down the road.

The bigger area that seems to accumulating is on bone health, primarily in females that are postmenopausal. That's an area that is emerging and I think vastly important and underrepresented from a global perspective.

So that it may delay or prevent osteoporosis? The hope here was shown in rodents and at McMaster University was one of the first studies to look at it. And then we've done successive studies in humans, in males 50 and above or postmenopausal females 50 and above. And after one year and two years of weight training, a bit higher dose than what's recommended for muscle was shown to reduce the rate of bone mineral density loss in hip region in females.

but it also improved bone strength and structure in males and females. So the thought here is exercise is required. No evidence has ever shown creatine by itself to have bone health benefits. But when you combine it with exercise, it seems to unlock that mechanical stimuli that may help preserve the skeleton as we get older. So if a young university student will fall on ice today, it's going to be embarrassing, but they can probably bounce back up.

Take your grandmother or grandfather, if they fall on ice today, unfortunately, they're at a higher risk of fracture. And sadly, if you break your hip and you need replacement, that leads to a lot of other chronic diseases and unfortunately, premature mortality. So the clinical aspects of creatine for bone health is emerging. And I think that's an area to stay tuned for. We're really hoping, can it actually have benefits in those diagnosed with osteoporosis or frailty?

Since you've mentioned women, I want to ask you, are the benefits of creatine supplementation equivalent in males and females? They're almost identical. The only area that we are a bit surprised is the increase in lean body mass is not as high in females across the lifespan, young or older, compared to males.

And I've talked to some great researchers that primarily focus on biological females. And logically, the only thing we can think of is maybe the fluctuations in estrogen might play a role. We don't think the menstrual cycle fluctuations have any influence. But as we get older, we think the estrogen production might contribute, especially for those older females where they might not get an increase in lean mass.

The good news is, I think from a functionality perspective, the relative increase in muscle performance, primarily strength, is identical. But if you're right with that hypothesis, then postmenopausal females would benefit as much as older males. They do benefit. We don't see the huge robust increase in lean mass. They do get a great increase in muscle performance. And again, going back to bone, that was the populations we saw some really favorable benefits.

So we're really hoping during the perimenopausal transition or the postmenopausal phases, maybe 12 months or until the end of their life, could this intervention of creatine in addition to exercise be a viable lifestyle intervention? We're certainly hoping.

I'm Katie Boland. And I'm Emily Hampshire, who didn't want to be here. On our new podcast, The Whisper Network, we want to speak out loud about all the stuff that we usually just whisper about, like our bodies, our cycles, our sex lives. Basically everything I text to you, Katie. So this is like your intimate group chat with your friends. And we can't wait to bring you into The Whisper Network. This journey is a nightmare for me. I'm doing it for all of us. So you're welcome.

Now let's move into what we know about creatine supplementation and brain function. What have studies shown about the potential cognitive benefits of creatine supplementation? It's really been emerging from a multifactorial perspective. So I'll put it to you based on the current body of evidence. So when it comes to cognition or memory,

There's been a few meta-analysis or individual studies showing some very, very small potential. But when you look closely at the data, and I think this is really important, it seems to only be effective during times of metabolic stress. So for example, sleep deprivation, hypoxia, getting individuals do a really mentally fatiguing task.

That's where creatine seems to come to the rescue. We don't see very good evidence at all if the individual brain or person is not stressed.

Now, I don't know anybody on the planet that doesn't go through stressors, but it seems to have the best effect when the brain is metabolically stressed. And it's likely that where the brain has the blood brain barrier, it says we don't need any from the bloodstream until we need help. That's maybe where supplementation can sort of just bring those levels or help back up the baseline. Again, if that's correct, then shift workers might benefit more.

from creatine supplementation? 100%. I fly to Germany tonight and I'm thinking of the pilot or how I'm going to be jet lagged tomorrow. Anything that causes metabolic stress, poor night's sleep, you're really stressed with work. As a professor, I see students stressed all the time. So

That's where the area we see the best benefits during metabolic stressors. And the etiology becomes from clinical depression, anxiety or other cognitive effects where their brain creatine levels are reduced.

And maybe supplementation will bring those levels either back up to normal or give them slightly greater increase. And that's probably why they seem some better effects. But if you're a young individual, adequate sleep, great diet, no adverse effects, you will not experience any greater benefits from supplementation. So I'm sure there are people listening to our conversation who are thinking too good to be true.

What are the known risks of taking too much creatine? Yeah, ironically, we really focus on this because we hear this quite often. And so from a clinical pathology perspective, we've looked at kidney and liver enzymes, blood cell count, heart. We don't see any adverse effects, even at higher dosages, up to about 11 grams of monohydrate a day for two years. Even if you have preexisting kidney or liver abnormalities, I think talk to your medical practitioner, make sure creatine's right for you.

But the totality of evidence-based research suggests that creatine safety profile is exceptional and there's really no adverse effects if taken at recommended dosages. You mentioned up to 11 grams of creatine monohydrate. Nobody is recommending that people take that much.

Well, I personally take 10 grams a day based on the whole body of research. So the issue around dosing is really, really outdated. For example, recommending as low as two to three grams for muscle is kind of like saying the RDA for protein is adequate, which we now know is not. Taking a little bit more from a clinical perspective shows no adverse effects. If anything, you might get more beneficial effects.

but there's certain ways to get up that dose if you're feeling comfortable with it. And there are side effects for some people, queasiness, for instance, maybe a little bit of nausea. Yeah, the side effects usually come from something that are usually prescribed only for athletes. It's called the initial stages creatine loading. And that's where you'll take about 20 grams a day for five to seven days.

If you do that, it's a very rapid way to benefit the muscle from a saturation perspective. But there's going to be two drawbacks. One is probably going to be water retention. Creatine is an osmotic compound. It takes water into the cell. So you might feel a bit puffier. And with that, you can get some GI tract issues where there's nausea, vomiting, maybe some diarrhea.

usually what I recommend if people do not want the loading phase and you certainly don't need to do that, start as little as two to three grams a day, see how you feel, and then you can slowly work your way up. And we've implemented that strategy in numerous studies in our lab, and it seems to be a very viable and effective way. Are there any side effects that people should be aware of besides that initial indigestion or diarrhea that can sometimes happen?

The only other one we've seen is that it's the water retention is the most prevalent. And I think you definitely do not need to do the loading phase. If you want to start small, that may help cause that water retention to subside. But we've actually just in the works of this longest paper to look at every single study ever produced. And there's no greater effects of creatine compared to placebo across the board. So we're really excited about getting that out there.

there. Who should not take creatine? I struggle with anybody on the planet that shouldn't consider it or may not get benefits. And that includes children, adolescents. There's great research there. Normal research in Australia looking at pregnancy and fetal development, likely because we're naturally producing it. Safety profile is exceptional. Obviously, we need a lot more long-term clinical trials, including blood biomarkers.

to confirm. But again, I'm not a medical doctor. I always recommend to individuals talk to their medical practitioner. If you have any history of medical abnormalities, please get medical clearance before creatine just because you want to make sure it's right for you. Do you need to take a bigger loading dose of creatine to get the benefits? No, you do not. If you're looking from a primarily muscle perspective, you could start as little as two to three grams a day

That will saturate the muscle in about 30 days and you will eventually get benefits. The lowest dose from a bone health perspective is about eight grams. Again, that's only in combination with weight training. From the neck up, it's a little bit divergent. There's been a great study out of Europe. They looked at four grams a day in people with long COVID and that seemed to accumulate in the brain after three months.

So, and again, the majority of the brain health studies look at that loading phase, 20 grams a day. So that's why I take 10. I did the basic math. And I think from a whole body perspective, I currently take 10 grams a day. That's just me. But you do not need to take a high dose. Two to three grams is a really good starting point. And I'm curious, was there any clinical benefit in that long COVID study after three months? There was. The biggest one was that the brain fogginess went down and there are incidences of headache.

The other big thing is that that small dose of creatine did accumulate using an MRS, which is like basically an MRI for the brain at three and six months in the white and gray matter. So,

Creatine, it can accumulate in the brain. It does take a little bit extra time because of the blood brain barrier. So I think if you were taking a small dose, which is probably the most viable for everybody listening, that will eventually accumulate. Once your muscles are full, hopefully some will trickle into your bone and then hopefully, obviously, others will trickle into the brain. And in the interest of disclosure, because I'm sure some of our listeners want to know, do you have research that is sponsored by industry?

We do. We usually get products that are donated, that are third-party tested. And I'm also advisor for two companies that make creatine. So we always talk about evidence-based research with that, but that's a really good, important disclosure. Darren Kando, I want to thank you for coming on The Dose to talk about creatine. I'll be interested in hearing the reaction that we get from our listeners. Thank you so much for having me.

Darren Kando is a professor at the Faculty of Kinesiology and Health Studies and director of the Aging Muscle and Bone Health Laboratory at the University of Regina. He's received research funding from the Canadian Institutes of Health Research, Canada Foundation for Innovation, the Saskatchewan Health Research Foundation, National Institutes of Health and from industry. Here's your dose of smart advice. Creatine is formed naturally in the liver, pancreas, kidneys and the brain and is found in every cell of the body.

our bodies manufacture creatine and we also consume it from animal protein and as a dietary supplement. Some of the best dietary sources include wild game, red meat, fish, particularly herring, salmon and tuna and most types of milk and cheese. Vegans likely need to top up creatine with seeds, grains, nuts and legumes. Creatine supplements are popular amongst athletes and people who do regular exercise.

There is evidence that creatine can increase muscle mass, improve athletic performance and hasten recovery. There's also a growing body of evidence that it improves muscle performance in older adults, particularly when combined with exercise. It also appears to improve bone health. A 2021 meta review of more than 1,000 studies found that creatine may help to control blood sugar levels, lower cholesterol and reduce the risk of stroke.

Recent studies suggest that creatine supplementation can improve cognition and partially nullify some of the adverse effects of sleep deprivation. Creatine appears to benefit women as well as men. Creatine is not an anabolic steroid and is not related to testosterone. It has a completely different chemical structure. Current evidence does not suggest that creatine increases the various forms of testosterone and does not cause hair loss.

Creatine monohydrate is the preferred form to get the health benefits. The general dose recommendation is 3 to 5 grams per day. That daily dosage is relatively well tolerated.

Current evidence suggests that you don't need to load creatine to get the benefits. Some research also suggests that 15 to 30% of people who take creatine experience very few noticeable muscle performance benefits. If you have topics you'd like discussed or questions answered, our email address is thedoseatcbc.ca. If you liked this episode, please give us a rating and review wherever you get your podcasts.

This edition of The Dose was produced by Samir Chhabra. Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your health care provider. I'm Dr. Brian Goldman. Until your next dose. For more CBC Podcasts, go to cbc.ca slash podcasts.