Friday Favorites: What Is Creatine? Its Sarcopenia Benefits and Potential Side Effects?

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When accompanied by a progressive strength-training regimen, 3 grams of creatine a day may improve muscle performance in older adults. A misinterpretation of lab tests may explain concerns over kidney safety with creatine supplementation.

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Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.

Creatine is a compound formed naturally in the human body that is primarily involved in energy production in our muscles and brain. It’s also naturally formed in the bodies of many animals we eat, and so, when we eat their muscles, we can also take in some creatine through our diet. (It was named after kreas, the Greek word for “meat,” in which it was first isolated.) We need about two grams a day; so, those who eat meat may get like one gram from their diet, and their body makes the rest from scratch. There are rare birth defects where you’re born without the ability to make it, in which case you have to get it all externally through diet. But otherwise, our bodies can make as much as we need to maintain normal concentrations in our muscles.

When people cut out meat, the amount of creatine floating around in their bloodstream goes down. But the amount in your brain remains the same, because your brain just makes all the creatine it needs. The level in vegetarian muscles is lower, but that doesn’t seem to affect performance, as both vegetarians and meat-eaters respond to creatine supplementation with similar increases in muscle power output. And if vegetarian muscle creatine was insufficient, then presumably they would have seen an even bigger boost. So basically, when you eat meat, that just means your body doesn’t have to make as much.

If creatine muscle content dropped as we grew older, that might help explain age-related muscle loss. But that doesn’t seem to be the case. Biopsies taken from the muscles of young and old adults show no difference in creatine content. Still, if it improves performance, maybe it would help. According to the International Society of Sports Nutrition, creatine monohydrate is the single most effective ergogenic supplement available to athletes for increasing exercise capacity and lean body mass during training. It’s no wonder surveys show as many as 70+ percent of collegiate athletes have used creatine supplements. What can it do for older adults?

Without exercise? Nothing. Most studies on creatine supplementation alone show no benefits for muscle mass, strength, or performance. This makes sense, given the mechanism. Creatine supplementation delays muscle fatigue. This enables people to work out longer and harder, and it’s that additional volume and intensity that leads to the muscle benefits. So, creatine alone doesn’t help, and creatine taken in the context of the same training that’s carefully controlled and deliberately equalized doesn’t help either. But let people exercise as much as they can, and most studies on creatine supplementation for the prevention and treatment of sarcopenia (meaning age-related muscle loss) show augmented lean mass, as it does in young adults.

Adding three to five grams of creatine a day to two to three days of resistance training a week added an additional three extra pounds of lean mass over an average duration of about four months. Now, some of this lean mass may be water weight, not muscle. Creatine causes water retention that can show up as lean mass. But compared to placebo, creatine combined with resistance exercise increases muscle strength as well. And the additional gains in mass and strength can persist as long as 12 weeks after stopping the creatine in older adults, as long as the resistance training is maintained. So obviously, it’s not all just water weight.

A reason I never advocated for creatine supplementation in older adults for muscle preservation was because systematic reviews up through 2017 concluded that adding creatine to training shows mixed results for muscle mass and strength, and it did not appear to translate to improved functioning. However, an updated meta-analysis found a significant improvement over placebo in sit-to-stand test performance, which is a decent predictor of reduced falls risk. Again, this was mostly only when accompanied by strength training. There have still been no consistent benefits discovered for just supplementing with creatine alone. So, creatine should always be prescribed with a progressive strength training regimen.

The Society for Sarcopenia, Cachexia, and Wasting Disease convened an expert panel that, despite the lack of long-term trials, suggested creatine be indeed used for the management of sarcopenia. The recommended dose to achieve muscle saturation is three grams a day. Within a month at that slow steady rate, you achieve the same muscle levels as loading with 120 grams over a period of a week. Note, though, it takes at least 12 weeks of creatine-supplemented resistance training to see a significant additive effect. Recent evidence suggests taking it after exercise might be slightly preferable to before, but this has yet to be verified.

Are there any side effects? We’ll find out next.

The Society for Sarcopenia, Cachexia, and Wasting Disease convened an expert panel that, despite the lack of long-term trials, suggested creatine be used for the management of age-related muscle loss––also known as sarcopenia. Are there any creatine side effects? Well, if one can extrapolate from mice, one side effect may be longevity. The average healthy lifespan of creatine-fed mice was found to be nine percent more than control mice, and they performed better on neurobehavioral tests, especially improved memory skills. But is taking creatine safe?

One can take a bit of comfort in the fact that it’s one of the world’s best-selling dietary supplements, with literally billions of servings taken, and the only consistently reported side effect has been weight gain, presumed to be from water retention. The only serious side effects appear to be among those with pre-existing kidney diseases taking whopping doses of like 20 grams a day for weeks.

The bottom line, according to the European Food Safety Authority, is that doses of up to three grams a day are unlikely to pose any risk “provided high purity creatine is used.” Dietary supplements are not regulated by the FDA, and may not actually contain what’s on the label or, in the case of creatine, may be tainted with contaminants generated during the industrial production process. When researchers looked at 33 samples of creatine supplements made in the U.S. and Europe, they all did actually contain creatine. That’s good. But half exceeded the maximum level recommended by food safety authorities for at least one contaminant. The researchers recommend that consumers choose products from producers that ensure the “highest quality control.” But that’s easier said than done.

One third-party supplement testing outfit that tested for impurities chose BulkSupplements brand as their top pick, which also happened to be the cheapest, at about 10 cents per daily three-gram serving, which is a level teaspoon. What about just getting it from meat? You could get those three grams of creatine eating about five steaks a day, since cooking destroys about 20 percent. But the heat reacts with the creatine and amino acids in meat to create carcinogenic heterocyclic amines––one of the reasons meat is considered to be cancer-causing. A separate safety concern was raised that creatine in supplement form could potentially form a different carcinogen, known as N-nitrososarcosine, when it hit the acid bath of the stomach. But when actually put to the test, this does not appear to be a problem.

Some have argued caution for creatine use among those with kidney issues. This concern appears to derive in part from a misinterpretation of laboratory data. The blood levels of a different compound—creatinine—is used as a marker of kidney function. It is a muscle metabolism waste product that is regularly cleared out by well-functioning kidneys. So, if your levels rise, maybe your kidneys aren’t doing so good.

But where does creatinine come from? The breakdown of creatine. So, if you take extra creatine, your creatinine levels in your blood could rise, giving the false impression that your kidneys are malfunctioning. But instead, you’re just making more, rather than clearing less. For patients who take creatine, doctors can consider other kidney function tests, such as blood levels of cystatin C levels, a waste product that is more independent of dietary intervention. So, tell your healthcare professional if you start creatine. Overall, creatine supplementation appears to be safe for the kidneys, but the longest study to date is less than three years. So, true long-term studies are lacking.

Please consider volunteering to help out on the site.

Motion graphics by Avo Media

Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.

Creatine is a compound formed naturally in the human body that is primarily involved in energy production in our muscles and brain. It’s also naturally formed in the bodies of many animals we eat, and so, when we eat their muscles, we can also take in some creatine through our diet. (It was named after kreas, the Greek word for “meat,” in which it was first isolated.) We need about two grams a day; so, those who eat meat may get like one gram from their diet, and their body makes the rest from scratch. There are rare birth defects where you’re born without the ability to make it, in which case you have to get it all externally through diet. But otherwise, our bodies can make as much as we need to maintain normal concentrations in our muscles.

When people cut out meat, the amount of creatine floating around in their bloodstream goes down. But the amount in your brain remains the same, because your brain just makes all the creatine it needs. The level in vegetarian muscles is lower, but that doesn’t seem to affect performance, as both vegetarians and meat-eaters respond to creatine supplementation with similar increases in muscle power output. And if vegetarian muscle creatine was insufficient, then presumably they would have seen an even bigger boost. So basically, when you eat meat, that just means your body doesn’t have to make as much.

If creatine muscle content dropped as we grew older, that might help explain age-related muscle loss. But that doesn’t seem to be the case. Biopsies taken from the muscles of young and old adults show no difference in creatine content. Still, if it improves performance, maybe it would help. According to the International Society of Sports Nutrition, creatine monohydrate is the single most effective ergogenic supplement available to athletes for increasing exercise capacity and lean body mass during training. It’s no wonder surveys show as many as 70+ percent of collegiate athletes have used creatine supplements. What can it do for older adults?

Without exercise? Nothing. Most studies on creatine supplementation alone show no benefits for muscle mass, strength, or performance. This makes sense, given the mechanism. Creatine supplementation delays muscle fatigue. This enables people to work out longer and harder, and it’s that additional volume and intensity that leads to the muscle benefits. So, creatine alone doesn’t help, and creatine taken in the context of the same training that’s carefully controlled and deliberately equalized doesn’t help either. But let people exercise as much as they can, and most studies on creatine supplementation for the prevention and treatment of sarcopenia (meaning age-related muscle loss) show augmented lean mass, as it does in young adults.

Adding three to five grams of creatine a day to two to three days of resistance training a week added an additional three extra pounds of lean mass over an average duration of about four months. Now, some of this lean mass may be water weight, not muscle. Creatine causes water retention that can show up as lean mass. But compared to placebo, creatine combined with resistance exercise increases muscle strength as well. And the additional gains in mass and strength can persist as long as 12 weeks after stopping the creatine in older adults, as long as the resistance training is maintained. So obviously, it’s not all just water weight.

A reason I never advocated for creatine supplementation in older adults for muscle preservation was because systematic reviews up through 2017 concluded that adding creatine to training shows mixed results for muscle mass and strength, and it did not appear to translate to improved functioning. However, an updated meta-analysis found a significant improvement over placebo in sit-to-stand test performance, which is a decent predictor of reduced falls risk. Again, this was mostly only when accompanied by strength training. There have still been no consistent benefits discovered for just supplementing with creatine alone. So, creatine should always be prescribed with a progressive strength training regimen.

The Society for Sarcopenia, Cachexia, and Wasting Disease convened an expert panel that, despite the lack of long-term trials, suggested creatine be indeed used for the management of sarcopenia. The recommended dose to achieve muscle saturation is three grams a day. Within a month at that slow steady rate, you achieve the same muscle levels as loading with 120 grams over a period of a week. Note, though, it takes at least 12 weeks of creatine-supplemented resistance training to see a significant additive effect. Recent evidence suggests taking it after exercise might be slightly preferable to before, but this has yet to be verified.

Are there any side effects? We’ll find out next.

The Society for Sarcopenia, Cachexia, and Wasting Disease convened an expert panel that, despite the lack of long-term trials, suggested creatine be used for the management of age-related muscle loss––also known as sarcopenia. Are there any creatine side effects? Well, if one can extrapolate from mice, one side effect may be longevity. The average healthy lifespan of creatine-fed mice was found to be nine percent more than control mice, and they performed better on neurobehavioral tests, especially improved memory skills. But is taking creatine safe?

One can take a bit of comfort in the fact that it’s one of the world’s best-selling dietary supplements, with literally billions of servings taken, and the only consistently reported side effect has been weight gain, presumed to be from water retention. The only serious side effects appear to be among those with pre-existing kidney diseases taking whopping doses of like 20 grams a day for weeks.

The bottom line, according to the European Food Safety Authority, is that doses of up to three grams a day are unlikely to pose any risk “provided high purity creatine is used.” Dietary supplements are not regulated by the FDA, and may not actually contain what’s on the label or, in the case of creatine, may be tainted with contaminants generated during the industrial production process. When researchers looked at 33 samples of creatine supplements made in the U.S. and Europe, they all did actually contain creatine. That’s good. But half exceeded the maximum level recommended by food safety authorities for at least one contaminant. The researchers recommend that consumers choose products from producers that ensure the “highest quality control.” But that’s easier said than done.

One third-party supplement testing outfit that tested for impurities chose BulkSupplements brand as their top pick, which also happened to be the cheapest, at about 10 cents per daily three-gram serving, which is a level teaspoon. What about just getting it from meat? You could get those three grams of creatine eating about five steaks a day, since cooking destroys about 20 percent. But the heat reacts with the creatine and amino acids in meat to create carcinogenic heterocyclic amines––one of the reasons meat is considered to be cancer-causing. A separate safety concern was raised that creatine in supplement form could potentially form a different carcinogen, known as N-nitrososarcosine, when it hit the acid bath of the stomach. But when actually put to the test, this does not appear to be a problem.

Some have argued caution for creatine use among those with kidney issues. This concern appears to derive in part from a misinterpretation of laboratory data. The blood levels of a different compound—creatinine—is used as a marker of kidney function. It is a muscle metabolism waste product that is regularly cleared out by well-functioning kidneys. So, if your levels rise, maybe your kidneys aren’t doing so good.

But where does creatinine come from? The breakdown of creatine. So, if you take extra creatine, your creatinine levels in your blood could rise, giving the false impression that your kidneys are malfunctioning. But instead, you’re just making more, rather than clearing less. For patients who take creatine, doctors can consider other kidney function tests, such as blood levels of cystatin C levels, a waste product that is more independent of dietary intervention. So, tell your healthcare professional if you start creatine. Overall, creatine supplementation appears to be safe for the kidneys, but the longest study to date is less than three years. So, true long-term studies are lacking.

Please consider volunteering to help out on the site.

Motion graphics by Avo Media

Doctor's Note

Learn about the connection between creatine and homocysteine in Should Vegetarians Take Creatine to Normalize Homocysteine? and The Efficacy and Safety of Creatine for High Homocysteine.

I first talked about the contamination issue a decade ago in Creatine Brain Fuel Supplementation.

For more on how to live your longest, healthiest life, see my book How Not to Age. (As always, all proceeds I receive from all my books are donated to charity.)

The original videos aired on September 25 & 27, 2023

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