Should You Be Taking Creatine?

I remember friends talking about creatine making them 'fly' while racing, back in the late 1990's, when I was still competing. Now, it seems that taking creatine is in vogue again after a few patients asked for my opinion about whether creatine is performance enhancing.

Creatine use back in the 90's was popular because it actually did what was claimed on the container (unlike many other supplements). It definitely changed how sports nutrition was viewed.

Creatine is a natural compound in our body produced from amino acids. It is also found in red meat and some fish. In our muscles, it is called phosphocreatine (or free creatine) where it is necessary for enabling movement and exercise. Phosphocreatine is responsible for quickly restoring ATP levels in muscles, which functions as the 'energy currency' for cells. 

ATP is broken down (or used) when our muscles contract during exercise and other activities. Phosphocreatine provides a qiuck pool of energy to allow quick restoration of ATP, which is fuel especially for high intensity exercise. Since creatine exist only in small amounts in the body, it is enough to fuel about 10 seconds of intense effort or all out sprint. Hence this is the 'free creatine' energy we all have in our bodies when needed for that 10 seconds worth of intense exercise.

Note that the body can also produce ATP from carbohydrates and fat, but it is a relatively slow process.

How creatine works is that it is able to produce strength gains because it enhances the short term, high intensity energy pathway in muscles called the phospho-creatine (PC) system. 

If the PC system is enhanced, it allows our muscle fibers to contract vigorously for longer periods allowing more intense loading and fatigue for the muscles. After the muscles break down, it produces greater repair and growth stimulus with adequate rest and nutrition This ultimately results in greater strength gains.

Taking creatine supplements can increase creatine stores in the body by up to 30 percent. Many types of creatine are available, the cheapest and most researched being creatine monohydrate. Bear in mind that the pricier creatine hydrochloride and ethyl ester have not been proven to be superior.

Many people who take creatine start with a loading phase of 20-30 grams per day (for up to 7 days) to saturate stores quickly, leading to a rapid increase in muscle stores of creatine. Subsequently, they take 3-5 grams daily to maintain levels.

Those who choose not to load will consume 3-5 grams daily. Research shows this is just as effective and it will take up to a month to maximise stores this way before it has an effect. 

A known side effect of consuming creatine is weight gain since creatine causes water retention in your muscles. This weight gain varies between 1-3 kg and not everyone who takes creatine experiences it. It can also cause mild stomach discomfort when large doses are taken. Long term supplementation with high doses have been investigated and shown to be safe in healthy subjects (Kreider et al, 2017).

Creatine supplementation is extremely popular with sprinters, strength and power athletes, especially when their events last for less than 30 seconds. It increases muscle mass and strength during weight training as well as improving performance during competition. 

Since body weight is not as important in sprints, weight and power lifting, athletes from these sports can benefit as increases in performance more than compensates for the increase in body weight.

Those who participate in sports like soccer, basketball or hockey when intermittent short bursts of high intensity sprints and jumps are required will benefit with creatine supplementation. Specific tests where power output and speed are improved have been shown in athletes in such sports (Ramirez- Campillo et al, 2016).

What about endurance sports? In ultra events, the need for high intensity surges or bursts are less frequent, so as exercise duration increases, benefits of creatine reduces. Research on endurance sports are mixed though most show no benefit. An increase in body weight from consuming creatine may increase energy requirements and require greater power output.  

I was asked why I took creatine supplements since research does not show much support when I used to race triathlons. I mainly raced the Olympic distance (1.5km swim, 40km bike, 10 km run) triathlons where fellow competitiors may surge on the climbs during the bike or run section to breakaway or get a gap. As such, we do need to respond to such high intensity surges otherwise the race may be over if you get dropped. 

This was the main reason I thought taking creatine may help, since I needed to be able to sprint intermittently during my event, especially up slopes or near the end of a race. Studies that investigate cycling using stationary bikes where slight increases in body weight may not affect performances show benefits from taking creatine. This may occur in similar scenarios that I mentioned in a climb during a race or a sprint finish where there is a need for higher power output or speed (Murphy et al, 2005). 

At these times, phosphocreatine contribute heaps to energy production, so an increase in creatine stores may be helpful. Bear in mind that the increase in body weight that sometime accompanies creatine supplementation is sufficient to cancel out the benefits. Especially in a hilly or longer race.

Utimately I stopped taking creatine supplements after 3 months because I did put on 1-2 kg of body weight. In addition I was not sure if it helped my ability to sprint and close gaps. I naturally have a good amount of Type IIa and IIb fast twitch muscle fibers already so the weight gain was not justified.

If you, like my patients, have heard good results about creatine and want to try it, bear in mind the scenarios that I mentioned.

References

Kreider B, Kalman DS, Antonio J (2017). International Society Of Sports Nutrition Position Stand: Safety And Efficacy Of Creatine Supplementation In Exercise, Sport, And Medicine. J Int Soc Sp Nutr. 14:18. DOI: 10.1186/s12970-017-0173-z

Murphy AJ, Watsford ML, Coutts AJ et al (2005). Effects Of Creatine Supplementation On Aerobic Power And Cardiovascular Structure And Function. J Sci Med Sp. 8(3): 305-313. DOI: 10.1016/s1440-2440(05)80041-6.

Ramirez-Campillo R, Gonzalez-Jurado R, Martinez C et al (2016). Effects Of Plyometric Training And Creatine Supplementation On Maximal-intensity Exercise And Endurance In Female Soccer Players. J Sp Med Sci. 19(8): 682-687. DOI: 10.1016/j.jsams.2015.005. DOI: 10.1016/j.jsams.2015.10.005

Searching For Wellness?

A patient who came to our clinic yesterday mentioned that one of his staff had just left his team to start a wellness business.

Wellness seems to be a 'hot' industry at the moment. Wellness centers offering to improve your personal 'wellness' have sprouted up all over Singapore. Flotation therapy rooms, cryotherapy, ketamine clinics, juice cleansing bars, electromagnetic therapy centres etc, you can find them all in Singapore.

There is a space near where I live that offers everything from aromatherapy, massages, healing salts and art therapy, that advertises itself as a calm oasis for mind, body and soul. It has been two tough years with Covid-19 and perhaps more people need wellness centers to ease their stress and improve their mental health and physical well being. 

The wellness industry is getting bigger by the minute. A McKinsey survey last year estimates the wellness market to be in excess of 1.5 trillion with annual growth of 5-10 percent.

The wellness industry may offer people hope, especially when we do know that modern pharmaceuticals/ medicine cannot cure all ills. When a patient does not respond to conventional treatment, they will seek unorthodox treatment to see if it works. However the wellness movement may cause a general distrust of scientific authority. This could be an issue in pandemic times, when thousands have died through misinformation.

Singaporeans may remember the 65 year old grandmother who was hospitalised after taking Ivermectin at the urging of her religious friends to protect herself from Covid-19. 

There are skeptics who say that much of this wellness stuff does not work. Will lavender oil cure your depression? Will drinking lettuce juice help you sleep better? How about activated charcoal detoxifying your body? Vitamin supplements? 

I do not have anything against wellness centers. I am also not against using pharmaceuticals when needed, although they sometimes have harmful side effects. Pharmaceuticals are often aggressively marketed to doctors which then gets passed on to patients. As a result we are often overprescribed.

My son was recently prescribed a 'special' pair of spectacles costing over $500 on top of a $700 + consultation fee and asked to come in for multiple sessions of therapy to help with his vision. A second opinion with a pediatric opthalmologist confirmed that his eyes are normal. I immediately asked for a full refund for the glasses (which was independently checked to be a simple pair of reading glassess). My son has 6/6 vision and definitely does not need reading glasses.

I gues what I'm trying to get across here is my humble opinion to be aware as you explore wellness options. Don't be pressured to buy expensive packages at your first few sessions. See and feel for yourself if it works for you. Take your time to decide. Be wary of individuals or centres that prey on your fear in order to get you to commit. Seek second opinions.

Magnesium Supplements For Muscle Cramps?

Available from my local pharmacy

A patient came in today saying she went to a local running store and was advised to take some magnesium supplements as she cramps occasionally while racing. So she went ahead and bought some. She wanted my thoughts on whether they truly work since they seem to be the latest "silver bullet" that most runners seem to be taking.

Magnesium is an essential nutrient that's actually found in many of the foods we're already eating. It is actually abundant in our bodies. Our bodies need it to create new proteins, for energy production in cells, DNA synthesis etc. As it is essential, our bodies store it in our bones, where it can easily be accessed if needed. Since our bodies cannot produce it, we need to get it from our diet.

An adequate magnesium is needed for a healthy pregnancy and to produce enough milk after giving birth. It is also useful if you take diuretic drugs, proton pump inhibitors and if you're diabetic.

It is suggested that adults need 300-400 milligrams a day and you will get enough if you eat enough legumes (chickpeas, black and kidney beans), nuts, seeds, veggies (broccoli, cabbage, asparagus, kale and spinach), fatty fish (tuna, salmon and mackerel) and some fruits (avocado, bananas, figs, guava and raspberries).

It is estimated that 10-30 percent of people in developed countries may have a mild deficiency in magnesium (DiNicolantonio et al, 2018). Severe deficiencies are uncommon but easy to spot. Symptoms include loss of appetite, vomiting and fatigue and following that numbness, muscle cramps, seizures, personality changes and heart artery changes if the deficiency continues.

It is why those who sell these supplements tell athletes to take them - to prevent muscle cramps! But note that the muscle cramps are preceded by loss of your appetite, vomiting and fatigue. Not the muscle cramps when you're training hard or racing. Note that the muscle cramps that occur when you have a magnesium deficiency happens with activities of daily living (not while exercising/ racing). Not only the muscles in your feet and legs cramp, but also your facial and masticatory (chewing) muscles.

Those who sell magnesium tablets, body sprays, serum and bath salts will tell you their products will boost recovery, energy levels and promote DNA synthesis, bone strength and other important body functions. When something sounds too good to be true, it probably is. If you eat a healthy diet of the food listed above that is rich in magnesium, then you wouldn't need any magnesium supplements.

You will not benefit from taking magnesium supplements unless you're deficient. This can only be verified via a blood test.

If you are lacking magnesium, you can either eat food sources rich in magnesium or take supplements. There is no evidence that any form of magnesium (whether it is magnesium oxide, aspartate or citrate) is more easily absorbed by our bodies. So don't buy the most expensive brand or version of it.

As for magnesium creams, oils, sprays, flakes and bath salts etc, evidence suggest that they are not as effective as claimed (Grober et al, 2017).

So if you have done a blood test and have a magnesium deficiency, load up on magnesium rich food or go ahead take a cheap supplement.

"So that means I wasted my money" went my patient? Now you know. And you've read what causes muscle cramps.


References

Grober U, Werner T et al (2017). Myth Or Reality- Transdermal Magnesium? Nutrients 9(8): 813. DOI: 10.3390/nu9080813.

DiNicolantonio JJ, O'Keefe JH et al (2018). Subclinical Magnesium Deficiency : A Principal Driver Of Cardiovascular Disease And A Public Health Crisis. Open Heart. 5:e000668. DOI: 10.1136/openhrt-2017-000668.

Popping Vitamins Or Other Dietary Supplements?

I often get patients asking me if there's something they can take to recover faster (from their injury). Most of them seem to be taking some form vitamins or other dietary supplements already.

Have a look the next time you walk into a Guardian or Unity Pharmacy here. You’ll see lots of vitamins and supplements there for sale. Not to mention the few sales assistants who will tell you what you need to be taking.

In fact, earlier in April this year, The New York Times published an article on how older Americans are hooked on vitamins.

Do we really need to be taking any extra vitamins and supplements. I've written before why there is no evidence for taking glucosamine. If you're interested you can read more here.

This may seem as a shock for those of you who are already taking vitamins or any sort of dietary supplements. Many supposedly muscle building supplements make unproven claims and may even come with side effects.

In the journal article referenced below (Gliemann et al 2013), researchers found that resveratrol (an antioxidant found in red wine) actually limited the positive effects of cardiovascular exercise. It affects your VO2 max when taken daily in high concentrations.

Those of you who take fish oil supplements beware. There is evidence that men with high levels of the omega-3 fatty acid DHA in their blood (from the fish oil supplements) are at a higher risk of getting prostate cancer.

In fact, well known researcher Professor Pieter Cohen (who was sued by a supplement maker but Cohen won) said there are only two types of supplements. Those that are safe but don't work. And those that might work but have side effects, especially at higher than normal levels.

Most vitamins are in the first category. Taking a multivitamin daily will not harm you, but it usually won't help too much either. This is why major health organizations don't recommend supplements to healthy people.

Now don't get me wrong here, If you don't have enough Vitamin C, you can get scurvy. Without iron, you can become anemic. And if you don't get enough sunlight, you may need some Vitamin D. However, all three of the above can have negative effects at high doses. Same for Vitamin E and calcium.

Unless blood tests show that you're super deficient in a particular vitamin or mineral, there is no evidence that you should be popping those pills. Even so, it's better to be getting them from real food sources.

If you're an athlete, and you're taking antioxidants to boost recovery take note of what Dr Mari Carmen Gomez-Cabrera (who is a world leading researcher on anti-oxidants) published. The antioxidant pills that you pop suppresses the oxidative stress that signals to your body to adapt and get stronger. Meaning regular use of something seemingly mild and innocent like Vitamin C can actually block gains that you've trained so hard to get in your endurance boosting mitochondria (cells).

Dr Gomez-Cabrera suggests eating five servings of fruits and vegetables daily and you won't need to pop vitamin or other pills.

To put it bluntly, vitamins and other dietary supplements just plain useless or worse than useless. Of course you can still buy them and take them if you wish. You're just lining the pockets of those of manufacture and sell them.


References

Cohen P, Travis JC et al (2014). A Synthetic Stimulant Never Tested in Humans, 1,3- Dimethybutylamine (DBMA), Is Identified In Multiple Dietary Supplements.  7(1): 83-87. DOI: 10.1002/dta.1735.

Gliemann L, Friss J et al (2013). Resveratrol Blunts The Positive Effects Of Exercise Training On Cardiovascular Health In Aged Men. 591(20): 5047-5059. DOI: 10.1113/physiol.2013.258061.

Gomez-Cabrera MC, Domenech E et al (2008). Oral Administration Of Vitamin C decreases Muscle Mitochondria Biogenesis And Hampers Training-Induced Adaptations In Endurance Performance. Am J Clin Nutr. 87(1): 142-149. DOI: 10.1093/acjn/87.1.142.

PS -After I wrote the article, another patient who runs frequently asked about taking magnesium for muscle cramps. Read the article I wrote on what causes muscle cramps and save your money.