Creatine: The King of Training Supplements (Notes from the The Quan Coaching Podcast Episode 3)

· Creatine Introduction -

One of, if not the most popular training supplement with studies showing that 90% of those that take any training supplement are taking creatine

o NCAA survey demonstrated 15-40% of male athletes supplement with creatine while 0.2-3.8% of female athletes supplement with creatine

o The king supplement for strength, power, and muscle mass gains with great popularity in the bodybuilding world as well as sports relying on strength and power, with these sports having up to 80% of athletes using creatine

o $400 million in annual sales

o >2,500 scientific, peer-reviewed papers regarding “creatine supplementation”

· Physiology and Mechanism of Action

o Nitrogenous compound with precursors being the amino acids arginine, methionine, and glycine

o 95% is stored in skeletal muscle, 5% collectively is stored in the brain and testes

§ 2/3 stored in the phosphorylated form (phosphocreatine) and 1/3 stored as free creatine

o 1-2% is broken down each day into creatinine and excreted by the kidneys

§ Amounts to having to replenish 1-3g/day

o Produced mainly by the liver but also by the kidneys and pancreas

§ Accounts for ~1g/day

o Carnivorous diet accounts for ~1-2g/day

§ Found mainly in animal tissues (meat and seafood)

§ Vegetarian diets have very limited amounts of exogenous creatine (some found in eggs or dairy products)

§ Vegan diets have nearly no exogenous creatine

§ Some studies (not all) have shown that creatine supplementation is even more beneficial for vegetarians/vegans because certain muscle groups in vegans/vegetarians will have lower creatine levels (up to 10-20% lower) compared to those practicing an omnivorous diet

o Purpose in the body:

§ Phosphagen energy system:

· Creatine kinase reaction used to rapidly replete ATP

· CP stored in relatively small amounts compared to other energy substrates; thus, cannot be used for long-duration exercise

· Used for short duration, high-intensity exercise

o More CP in Type II muscle fibers (compared to Type I) = those with more Type II (fast twitch) are able to more quickly replete ATP through phosphagen system and perform more high intensity exercise

o Almost the sole energy system used for very high intensity exercise that is only being used for <6 seconds; also heavily involved (along with glycolysis) for high intensity exercise lasting <30 seconds

§ Weight/resistance training, speed training, plyometric/agility/power training

o In a high intensity 6 second bout: CP is decreased 35-57% from resting levels; at 30 seconds CP is decreased to 64-80% from resting levels; almost completely depleted with repetitive bouts

§ After this depletion, strength/speed/power has been shown to decrease as the phosphagen system and depletion of ATP/CP is the number one limiting factor for these high intensity exercises

§ Supplementing Creatine therefore allows for more potential to rapidly create ATP by increasing creatine concentrations within the muscle

· Vegetarians – 100 mmol/kg dry weight muscle

· Omnivorous diet – 120 mmol/kg

· With a creatine loading protocol – 140 mmol/kg

· With a creatine loading protocol with carbs/protein augmentation – 155 mmol/kg

· Up to a 55% increase in creatine levels through supplementation if eating a vegetarian diet and a 30% increase even if consuming an omnivorous diet

· Benefits

o ~15% increase in performance with maximal power and strength and repetitive sprint performance

§ Occurs after months of supplementation – which demonstrate that its effects are as a training supplement instead of a performance enhancer (aka its not like taking caffeine prior to working out which will immediately enhance performance over the time period that that dose lasts for)

· This will become important when we talk about dosing and timing

o Increase in fat free mass

§ 1-4.5 lb greater increase in fat free mass over a period of several weeks to months

§ Due to multiple reasons:

· If participating in resistance training, you will be able to perform more work (aka lift more weight) which will lead to increased stimulus for muscle synthesis

· Increased intracellular osmotic gradient due to increased creatine in cells draws water in

o Increased intracellular volume is an important stimulus for increased muscle synthesis

§ Will increase fat free mass even if not in resistance training but this increase has been shown to be moreso in those participating in resistance training program

o Because more energy can be drawn from the phosphagen system which does not result in lactate production; creatine supplementation has also been shown to increase the lactate threshold and therefore accordingly increase anaerobic capacity and even aerobic performance, demonstrated specifically in a study with rowers

§ Less significant of an effect size compared to effect size on strength/power/muscle mass

o May even decrease injuries/muscle cramping/heat stroke/dehydration (2003 study with D1 Football players over 3 year period)

§ Not great evidence and further studies are needed to see if this is a true benefit but studies have certainly demonstrated that creatine does not increase these injuries

· Adverse Effects

o Very small side effect profile

§ Anecdotal reports of GI upset, cardiovascular concerns, and muscle cramps; however, scientific controlled trials have not found any association between creating supplementation and any known side effects

o Due to the very large osmotic load during the loading phase, individuals may experience mild diarrhea or bloating

o During clinical trials in which creatine supplementation has been studied for potential clinical applications (neurodegenerative diseases (e.g., muscular dystrophy, Parkinson’s, Huntington’s disease), diabetes, osteoarthritis, fibromyalgia, aging, brain and heart ischemia, adolescent depression, and pregnancy), there have been studies demonstrating safety and toleration up to 30g/day for 5 years

o One hypothesized adverse effect is kidney damage, given the increased nitrogenous load that must be excreted (i.e. creatinine); however, this also has been debunked in both short term and long term studies (up to 5 years)

§ Will discuss more later

· Who It’s For

o Men and women

§ Most studies have been done in men; however, studies have demonstrated benefit for women as well

· Effect size for women may be lower than for men but importantly, the benefits mentioned above are still seen

o All ages

§ Has been evaluated for clinical use in varying ages all the way from infants to elderly

o I therefore recommend creatine for anyone undergoing a resistance training program and with extra emphasis for anyone whose top goals include:

§ Increased muscle mass

§ Increased strength

§ Increased speed/power

· How to supplement with creatine:

o Dose

§ Loading phase of 20-25 g per day (or 0.3 g/kg per day) for 5-7 days

· Allows us to saturate the muscle with creatine faster and arrive at that 30-55% increase in concentration faster than if we did not use the loading phase

§ Maintenance phase of 3-5 g per day (or 0.1 g/kg per day)

· Some studies have shown that larger athletes need up to 5-10 g per day so aim for at least 5 g if you are over 80 kg

§ Improved creatine retention by as much as 25% when taken with ~50g protein and ~50g carbs

§ Watch out for creatine dose in stock pre-workout drinks!

· Often only 1-2 g despite 3-5 g per day being the recommended dose that has been extensively scientifically studied

o Timing

§ Not a performance enhancer

§ The goal is to saturate the muscles with creatine = you can take it at any time (i.e., it doesn’t have to be before your resistance training session)

§ Ideally you would take it with a meal to augment retention

· Common Questions and Misconceptions (2021 paper from Antonio and colleagues - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7871530/)

o 12 important questions, all of which I have been asked at some point and some of which we have already touched on, but we will touch on all of them including the ones we’ve already talked about in order to review some important points

o 1. Does creatine lead to water retention?

§ During the short term, especially with a loading phase, total body water may increase due to the large increase in osmotic gradient

§ In long term, studies have demonstrated that there is no increase in total body water relative to muscle mass

· Increased muscle mass provides increased capacity for total body water regardless of whether or not creatine is supplemented

§ Short answer = after the first week, creatine does not likely cause increased water retention outside of the “desired” water retention that is related to increased ICW with increased muscle synthesis

o 2. Is creatine an anabolic steroid?

§ No. As previously discussed, creatine is a nitrogenous molecule derived from amino acids while anabolic steroids are androgenic compounds like we discussed last week and are of a completely different chemical structure

§ Anabolic steroids are a banned and unsafe substance while creatine is a legal and safe supplement

o 3. Does creatine cause kidney damage/renal dysfunction?

§ Short answer is as mentioned earlier – no it does not as proven by many short and long term studies

§ The reason for this question and misconception is 2 fold

· Misunderstanding of renal function markers:

o Creatine is broken down into creatinine and excreted by the kidneys

o Creatinine is the most common marker of kidney function

§ Because it is purely renally excreted, if creatinine level in the blood rises, it is assumed that the kidneys are damaged because they no longer have the same ability to excrete the creatinine

§ Correct in most cases but makes a major assumption – creatinine production is constant and equal amongst different individuals of the same weight

· If we are supplementing with creatine and/or if we have more muscle (which holds creatine) then we will be breaking down more creatine each day into creatinine, which will raise our blood levels

o This is then falsely assumed to mean kidney damage

· The big key to understand is that creatinine, while certainly a helpful tool, it is not a DIRECT marker of kidney damage – and muscle mass and creatine supplementation/levels need to be taken into account

· 1998 case study of individual taking creatine who had prior kidney disease demonstrated to have increasing creatinine levels after creatine supplementation

o Be careful about making huge conclusions based solely on case studies

o 4. Does creatine cause hair loss / baldness?

§ This miscondeption is quite a stretch and stems from a single study in which creatine supplementation was found to increase DHT (an androgen) in a sample size of ~20 rugby players. Increased DHT, being an androgen, can result in hair loss just as taking anabolic steroids can.

§ The subjects in the study did not actually demonstrate hair loss, but it was theorized that the increased in DHT could lead to hair loss

§ This increase in DHT due to creatine supplementation has not been replicated and studies have demonstrated that it does not increase any androgen levels

§ In short there is no evidence that creatine causes hair loss/baldness

o 5. Does creatine lead to dehydration and muscle cramping?

§ This misconception comes from the theory that creatine is an osmotic substance and keeps water trapped within muscle cells; thus, there is less circulating water that can be used for thermoregulation and blood circulation

§ However, as we previously mentioned this is nothing more than an incorrect theory as studies have disproven this theory with some studies even showing that muscle cramping and dehydration decreases with creatine supplementation

o 6. Is creatine harmful for children and adolescents?

§ As mentioned previously, creatine has been studied even in infants and was proven to be safe. That being said, there are a very limited amount of studies in children/adolescents

§ No study involving creatine supplementation has demonstrated significant side effects

§ Stands to reason based on current evidence that it is safe and this is what many have believed apparently as surveys have demonstrated that 21% of high school male athletes have used creatine and 3% of high school female athletes have used creatine

o 7. Does creatine increase fat mass?

§ This myth likely arose due to creatine increasing fat free mass and individuals not knowing whether it was from fat, muscle, or water

§ Many studies have been completed on the topic and demonstrated that creatine does not increase fat mass

· Most recently Forbes and colleagues conducted a meta analysis consisting of 609 participants >50 years old. Those supplementing with creatine where actually found to lose ~0.5kg more fat than those not on creatine

o 8. Is a creatine ‘loading-phase’ required?

§ The loading phase allows us to more quickly reach muscular creatine saturation by consuming 4x more than the maintenance dose for 5-7 days

§ This is not required to receive a long term benefit

§ We are essentially trying to get to a saturated level and we can either choose to get their quickly to start receiving these benefits faster or we can not use a loading phase and get there more slowly but surely by always consuming a maintenance dose

§ What the studies have shown is that at the 4 week point, individuals who used a loading phase will have the same concentration of creatine as those who did not

· Specifically at 28 days, creatine concentration was found to be the same (20% increase) in individuals who loaded at 20 g/day for 6 days compared to those who consumed 3 g/day for 28 days

§ Therefore, if you want to see the benefit at 6 days, a loading phase will be recommended; although you may have more potential to gain water weight over this short term period due to the high loading requirement and may experience some GI upset

§ To limit these possible side effects, only the maintenance dose can be taken and the same benefits will be received, but at a slower time frame (>4 weeks)

o 9. Is creatine beneficial for older adults?

§ Yes!

§ As mentioned it has been proven to be safe in clinical trials even for elderly

§ And an increasing amount of evidence for older individuals has demonstrated increased muscle mass and strength gains specifically in older individuals

o 10. Is creatine only useful for resistance / power type activities?

§ This is the main but not only benefit

§ We touched on this briefly previously that there are other potential benefits including:

· Possible decreased injury/cramp/heat stroke risk

· Increased anaerobic capacity and increased lactate threshold

· Increased muscle glycogen storage when taken with carbs

o Important for many types of exercise including aerobic training

· Possible clinical applications (may have possible neuroprotective effect, improve insulin sensitivity, etc)

o 11. Is creatine only effective for males?

§ No!

§ This is one of the biggest misconceptions as shown by the stats I’ve given throughout regarding the prevalence of creatine use in males vs females

§ Some studies have shown a slightly lower effect size in females compared to males but a significant effect (still close to 10-15% increase) is still seen in all the categories of strength, power, and muscle mass increase

§ Currently much research being done on the effect of estrogen and progesterone on creatine kinase or the phosphagen system

· CK is most active in females during menses and lowest during early pregnancy (and also declines with age)

· No human studies yet, but interesting animal studies demonstrating fetal growth protective effects with creatine supplementation during pregnancy

· Be on the lookout for human study results on this

o 12. Are other forms of creatine similar or superior to monohydrate and is creatine stable in solutions/beverages?

§ There are multiple formulations of creatine supplementation on the market

· Creatine salts, creatine HCl, creatine ethyl ester, creatine dipeptides, etc

o Marketed with erroneous claims of having lower adverse effects or being better absorbed

§ Monohydrate is 99% absorbed

§ Monohydrate has the most g of creatine per g of product compared to other formulations

§ We have already demonstrated how at the maintenance dose there are no true adverse effects

§ Other claims are that creatine monohydrate is not as soluble in water so we have other products such as creatine HCl which are more soluble and therefore a better product

· Not the case because the solubility of the creatine product has no influence on tissue absorption

§ In short, creatine monohydrate has all the evidence to back it for being the superior product

· Don’t let these false marketing schemes from people trying to break into the supplement industry influence you

· Summary:

o That was your crash course on probably the best safe and legal training supplement on the market.

o Not magic, but provides great benefit and is worth the money in my opinion

o If you are going to use any supplements, creatine should be the first you reach for

o Any questions or comments, please hit me up on the socials or contact me page on thequancoaching.com